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SURGERY 


SURGE  R Y 


BY 


JOHN    ALLAN    WYETH,  M.D.,  LL.D.   (University  of  Alabama) 

PRESIDENT   OF  THE   XEW   YORK  ACADEMY   OF    MEDICINE  ;    PRESIDENT  OF   THE    MEDICAL    FACULTY    OF.    AND    SURGEON- 
IN-CHIEF  TO  THE    SEVr  YORK    POLYCLINIC   MEDICAL  SCHOOL  AND   HOSPITAL;    EJi-PRESIDENT  OF  THE  AMERICAN 
MEDICAL  ASSOCIATION,    OF   THE   NEW  YORK   STATE   MEDICAL  ASSOCIATION,   AND    OF  THE  NEW  YORK  PATH- 
OLOGICAL SOCIETY  ;    FORMERLY    ATTENTJING     SURGEON    TO    MOUNT    SINAI     AND    TO    ST.    ELIZABETH'S 
HOSPITALS  ;     HONORARY    MEMBER    OF    THE    TEXAS    STATE    MEDICAL    ASSOCIATION    AND    OP 
THE    MEDICAL    SOCIETY    OF    NEW    JERSEY;     AUTHOR    OF    "ESSAYS    IN    SURGICAL 
ANATOMY  AND   SURGERY"  ;    AWARDED    THE    FIRST    AND    SECOND    PRIZES 
OF    THE    AMERICAN     MEDICAL    ASSOCIATION    IN    ISTS    AND    THE 
"BELL£WE  alumni  ASSOCIATION  PRIZE"  IN  1876,  ETC. 


WITH  S64  ILLUSTRATIONS 


MARIOX  SBIS  WYETH   &   COMPANY,  Publishers 

244  Lexia'Gton  AvEjfUE,  New  York  City 

1908 


'C- 


a-/ 


COPYEIGHT,    1908,    BY 

MAEION  Sms  WYETH   &.  COMPANY 


'"^^^ 


TO  THE  MEMOBY  OF  HIS  FEIEND 

J.    MARION    SIMS,    M.D.,    LL.D. 

WHOSE  BRILLIANT  ACHIEVEMENTS 
CARRIED   THE   FAME   OP  AMERICAN   SURGER-T 

THROUGHOUT  THE   CIVILIZED   WORLD 

THIS  BOOK  IS  AFFECTIONATELY   DEDICATED 

BY  THE   AUTHOR 


PEEFACE 

The  author's  original  "  Text-book  on  Surgery  "  was  published  in  1887, 
and  was  followed  by  two  subsequent  editions,  the  last  of  which  appeared  in 
1900.  These  editions  were  jjublished  by  D.  Appleton  and  Company,  from 
whom,  in  1907,  by  an  arrangement  mutually  satisfactory,  he  became  the 
owner  of  the  illustrations,  with  the  right  to  publish  an  entirely  new  work. 

In  this  book,  "  Wyeth's  Surgery,"  all  of  the  original  illustrations  which 
are  related  to  modern  technic  and  as  much  of  the  text  as  deals  with  the  science 
and  art  of  surgery  as  accejDted  and  practiced  at  this  date  have  been  retained, 
and  many  new  illustrations  have  been  added,  making  864  in  all,  of  which 
57  are  colored. 

It  has  been  the  author's  aim  to  present  not  only  the  major  operations  so 
concisely  that  this  work  may  be  made  available  for  quick  and  ready  reference, 
but  to  include  as  well  the  details  of  minor  surgery,  so  much  of  which  falls 
to  the  lot  of  the  general  practitioner.  Beyond  this  he  has  endeavored  to 
arrange  the  various  subjects  so  as  to  make  them  attractive  to  teachers  for  their 
undergraduate  pupils. 

While  in  a  single  volume  it  is  scarcely  possible  to  deal  exhaustively  with 
subjects  of  such  importance  as  surgical  pathology  and  the  process  of  repair  in 
the  various  tissues,  the  author  has  endeavored  to  present  concisely  the  essential 
features  of  infection  and  repair. 

In  the  chapter  devoted  to  the  eye,  he  begs  to  acknowledge  his  indebtedness 
for  many  valuable  suggestions  to  his  colleague,  Dr.  E.  0.  Born,  professor  of 
ophthalmology  in  the  New  York  Polyclinic  Medical  School  and  Hospital.  He 
has,  however,  taken  the  liberty  of  so  presenting  this  chapter  as  to  relieve  his 
colleague  of  any  responsibility  in  regard  to  whatever  may  be  expressed.  That 
portion  which  deals  with  refraction  is  reproduced  from  his  former  book,  and 
is  the  work  of  his  friend  and  colleague,  Dr.  David  Webster,  professor  emeritus. 

In  the  chapter  on  the  ear,  with  the  consent  of  the  author  and  publisher, 
he  has  made  free  use  of  the  excellent  work  on  "  Diseases  of  the  Ear  "  (D. 
Appleton  and  Company),  by  Dr.  E.  B.  Dench,  formerly  professor  of  otology 
in  the  New  York  Polyclinic  Medical  School  and  Hospital,  and  now  occupy- 
ing this  chair  in  the  University  and  Bellevue  Medical  College. 

The  chapters  on  the  blood  and  urine  have  been  carefully  revised  by  Prof. 


viii  PREFACE 

F.  M.  Jeffries,  of  the  Polyclinic  Laboratory,  to  whom,  and  to  Dr.  J.  C.  Taylor 
for  valuable  assistance  in  the  cliapter  on  diseases  of  the  female  genital  organs, 
lie  here  makes  formal  acknowledginent. 

He  is  deejjly  indebted  to  the  various  publishing  firms  and  to  his  many 
professional  friends  for  their  permission  to  use  the  illustrations  from  books 
or  periodicals  issued  by  them.  He  has  drawn  extensively  upon  his  former 
publishers,  D.  Appleton  and  Company,  with  whom  his  relations  have  always 
been  most  satisfactory,  and  also  from  W.  B.  Saunders  Company,  William  Wood 
and  Company,  Cloyd  J.  Head  and  Company,  the  publishers  of  "  Murphy's 
Year  Book  on  Surgery,"  the  "  Journal  of  the  American  Medical  Association," 
"  Surgery,  Gynecology,  and  Obstetrics,"  the  "  ISTew  York  Medical  Record," 
and  the  "  Annals  of  Surgery."  He  has  endeavored  in  each  instance  to  credit, 
either  in  the  text  or  in  the  lines  explanatory  of  the  illustration,  the  source 
from  which  it  was  obtained. 

To  his  faithful  and  efficient  assistant.  Dr.  Charles  E.  Hancock,  he  is 
indebted  for  the  carefully  prepared  Index. 

The  Adthoe. 

Borough  of  Manhattan,  Greater  New  York. 


WYETH'S    SURGERY 


CHAPTER    I 

A  SURGICAL  OPERATION THE  PREP-ARATIOX   OF   THE  PATIENT,   ASEPSIS,   ANTISEPSIS, 

THE    OPEKATIXG    ROOM,    IXSTRUJIEXTS,    DRESSINGS,    ETC. 

Life  is  a  struggle  for  existence  between  the  tissues  of  tlie  Ijody  and  the  myriad 
organisms  -n-liich  are  constantl}^  seeking  to  devour  tliem.  That  whicli  we  call  health 
is  the  normal  resistance  of  the  tissues  to  the  destroying  organisms  of  disease.  Since 
the  chief  role  in  defense  is  played  by  the  leucocytes  (phagocytes),  recovery  in  large 
measure  depends  upon  proper  nutrition  and  the  absence  of  those  conditions,  chiefly 
local,  which  favor  the  lodgment  and  proliferation  of  pathogenic  organisms. 

It  follows  that  in  the  performance  of  an  operation  not  only  should  that  essential 
principle  of  surgical  technic — viz.,  the  least  possible  traujiatis:m — be  regarded, 
but  that  by  careful  nutrition  the  resistance  of  the  tissues  should  be  brought  as  near 
the  normal  as  possible. 

It  also  follows  that  when  an  emergency  does  not  make  an  immediate  operation 
imperative,  the  careful  preparation  of  the  patient  does  away  with  many  of  the 
dangers  of  the  operation  and  the  discomforts  of  the  ansesthetic. 

The  time  required  will  vary  with  the  condition  of  the  subject  and  the  character 
of  the  proposed  operation.  The  alimentary  canal  should  under  all  circumstances 
be  thoroughly  emptied,  preferal:)ly  by  calomel  triturates  one  half  grain  each,  given 
every  half  hour  until  two  grains  are  taken,  to  be  followed  in  from  ten  to  twelve 
hours  by  one  or  two  tablespoonfuls  of  castor  oil.'^ 

Next  in  order  of  preference  is  Epsom  salts,  taken  upon  an  empty  stomach  and, 
as  generally  advised,  in  the  early  morning  one  or  two  hours  before  eating.  The 
emploTOient  of  Seidlitz  powder,  or  any  agent  which  develops  gas  within  the  ali- 
mentary canal,  is  objectionable. 

Should  an  operation  upon  the  alimentary  canal  or  within  the  abdominal  cavity 
be  intended,  this  treatment  may  be  repeated  in  twenty-four  hours,  and  again,  if 
deemed   advisable,   always    earefulh'   guarding   against   too   great   tissue  waste  by 

'  The  disagreeable  taste  of  this  invaluable  agent  may  be  entirely  disguised  by  pouring  into 
the  bottom  of  a  glass  one  or  two  ounces  of  syrup  of  sarsaparilla,  aerating  this  with  carbonic- 
acid  gas  discharged  from  a  siphon,  pouring  the  oil  carefully  into  the  center  of  this  mixture  and 
drinking  at  once.  There  is  no  more  efficient  and  useful  purgative  in  the  Pharmacopceia.  Nothing 
can  equal  the  combination  with  calomel  as  above  directed  in  preparing  a  patient  for  a  surgical 
operation  or  in  a  general  cleansing  of  the  alimentary  canal. 

The  thoughtful  physician  or  patient  will  realize  the  necessity  of  eating  slowly  and  of  thoroughly 
masticating  and  insalivating  all  ingesta.  Even  liquids  should  be  slowly  sipped.  By  thorough 
mastication  that  which  is  swallowed  is  more  readily  taken  hold  of  by  the  digestive  fluids,  while 
coarse  and  indigestible  substances  are  recognized  in  the  mouth  and  may  be  expelled.  The 
conditions  in  the  alimentary  canal  after  about  the  fortieth  year  differ  from  those  of  earlier  life, 
and  suggest  certain  modifications  of  diet.  The  strength  of  the  involuntary  bowel  muscle  begins 
to  be  impaired,  as  well  as  the  voluntary  system;  the  digestive  fluids  are  not  so  efficient,  which 
with  diminished  peristalsis  favors  the  putrefaction  of  ingesta  and  the  development  of  toxines 
from  bacterial  proliferation.  Any  mental  disturbance  or  overstrain  interferes  with  digestion. 
The  shock  of  an  operation,  the  effects  of  an  ancesthetic,  or  even  confinement  in  bed  adds  to  the 
inertia  of  the  alimentary  canal,  and  suggests  the  necessity  of  limiting  the  quantity  of  ingesta 
from  all  of  which  bacteria  should  be  excluded.  It  follows  that  age,  accident,  or  disease  suggests 
the  minimum  of  meats  or  any  nitrogenous  articles,  and  that  cleansing  the  alimentary  canal 
both  by  irrigation  and  by  purgation  is  more  than  ordinarily  essential  in  any  of  these  conditions. 

1 


^  A  SURGICAL  OPERATION 

excessive  purgation.  If  chronic  or  acute  colitis  should  prevail,  or  if  the  patient 
suffers  from  habitual  constipation,  a  thorough  irrigation  of  the  large  bowel  with 
normal  salt  solution,  the  injections  being  made  with  the  patient  in  the  knee- 
shoulder  position,  should  be  made. 

In  many  instances  the  stomach  requires  to  be  emptied  not  only  of  ingesta,  but 
of  mucus,  when,  as  so  frequently  is  the  case,  gastric  inertia  is  present.  Aljstinenee 
from  solid  food  for  at  least  twelve,  and  preferably  twenty-four,  hours  before  an 
operation  is  advisable,  although  a  concentrated  liquid  or  semi-liquid  nourishment, 
partially  or  completely  predigested  if  necessary,  should  be  given.  Gastric  lavage 
should  also  be  practiced,  especially  in  operations  upon  the  stomach  or  the  upper 
two  feet  of  the  alimentary  canal. 

When  the  operative  procedure  is  confined  to  the  anal  outlet  (as  in  haemorrhoids) 
or  to  the  external  genitals,  no  purgation  should  be  administered  later  than  twenty- 
four  hours  before  the  operation.  It  is  always  advisable  to  give  a  thorough  colon 
irrigation  twelve  hours  before,  so  that  this  may  be  discharged  or  absorbed  before  the 
anassthetic  is  begun. 

In  all  of  these  procedures  the  introduction  and  inflation  of  a  Barnes'  dilator 
to  a  depth  of  six  inches  in  the  bowel  will  prevent  any  possible  soiling.  Should  the 
dilator  not  be  convenient,  a  gauze  plug,  to  wliich  a  strong  cord  is  attached,  should 
be  lubricated  with  vaseline  and  passed  deeply  into  the  bowel  along  the  concave  side 
of  a  Sims'  speculum. 

If  tonics  are  needed  to  improve  the  condition  of  the  blood,  they  should  be  care- 
fully selected  as  well  as  a  diet  list,  which  latter  should,  so  far  as  possible,  exclude 
bacteria  and  all  foods  not  readily  digested.^  B}'  rest  and  careful  feeding  the  hemo- 
globin should  be  brought  to  the  proper  percentage. 

A  careful  study  of  the  lieart,  lungs,  and  kidneys  should  also  be  made.  The 
mental  condition  of  the  patient  should  be  the  subject  of  careful  consideration,  and 
the  most  hopeful  view  as  to  the  outcome  of  the  proposed  operation  should  be  taken, 
even  to  the  extent  of  concealing  (at  least  from  the  patient)  any  extreme  danger 
which,  in  the  judgment  of  the  surgeon,  is  about  to  he  incurred. 

In  preparing  the  operative  field,  a  wide  area  should  be  thoroughly  shaven, 
preferably  twelve  hours  before  the  operation,  scrubbed  with  sterile  soap,  brush, 
and  warm  water,  mopped  well  with  mercuric  chloride  1-1000,  and  protected  by 
several  layers  of  sterile  towels,  gauze,  or  cotton,  lield  in  place  by  a  bandage.  When 
exposed  for  the  operation,  the  skin  should  he  again  mopped  in  mercuric-chloride 
solution,  dried,  and  then  tlioroughly  wet  with  ether  to  dissolve  the  infected  fat 
in  the  sebaceous  follicles,  and  with  alcohol,  and  lastly  again  with  the  mercuric- 
chloride  solution. 

Under  no  circumstances  should  an  excessive  quantity  of  water  or  any  solution 
be  employed.  To  permit  a  patient  to  remain  soaked  in  solutions  during  an  opera- 
tion is  reprehensible  in  the  extreme.  It  is  an  inexcusable  lowering  of  the  body  heat 
and  the  patient's  resistance.  The  parts  should  be  mojiped  with  ether  and  alcohol 
by  the  use  of  cotton  pellets. soaked  in  these  materials,  and  not  poured  on. 

When  the  umbilicus  is  in  the  operative  field,  this  should  in  addition  be  filled 
with  iodine  solution. 

All  parts  of  the  patient's  body  not  exposed  for  operation,  as  well  as  the  oper- 
ating table,  should  be  covered  with  sterile  sheets  or  towels. 

'This  diet  list  may  be  modified  to  suit  any  particular  case.  Drinks:  Water  that  has  been 
boiled  and  allowed  to  cool,  not  ice  water.  The  purest  milk  obtainable;  if  in  doubt  about  its 
purity,  Pasteurize  by  heating,  not  quite  to  the  boiling  point.  Weak  Ceylon  tea,  drinking  it  with 
a  large  proportion  of  hot  water.  Do  not  drink  a  great  deal  of  water  while  eating.  Take  as 
much  as  you  can  conveniently  dispose  of  between  meals,  beginning  one  hour  after  each  meal. 
Soups:  Simple,  clear  soups;  consomm^,  chicken  broth,  beef  broth,  lamb  broth,  cream  of  celery. 
Meats:  Beef  (roasted  or  broiled).  Mutton,  lamb,  chicken,  turkey,  birds,  venison  (roasted,  broiled, 
or  boiled).  Lean  of  fish,  preferably  tender  white  meat  and  not  oily.  No  sweets.  CercaZs:  Well- 
cooked  rice,  mixed  with  beaten  whites  of  egg,  flavored,  and  baked  in  a  hot  oven;  served  warm. 
Wheatena;  shredded  wheat  (browned);  Pettijohn's  breakfast  gem;  crust  of  roll;  crust  of  bread; 
dry  toast.  Fresh  butter.  Vegetables:  All  uncooked  vegetables  should  be  avoided.  A  very 
limited  quantity  of  white  potatoes,  mashed  and  baked,  with  a  little  cream.  Beans,  peas,  carrots, 
cooked  celery.  Fruits:  Stewed  prunes  occasionally.  Very  ripe  peaches  in  moderate  quantities, 
without  sugar  or  cream.     A  few  Malaga  or  Tokay  grapes,  not  swallowing  the  hulls  or  seeds. 


A  SURGICAL  OPERATION  3 

Asepsis  implies  the  alisence  of  infective  organisms  from  the  tissues;  antisepsis, 
the  effort  to  destroy  those  already  present. 

When  it  is  ]aioT\'n  that  cell  proliferation  in  the  process  of  repair  in  a  ^vo^md 
from  which  septic  organisms  are  excluded  (or  in  which  their  proliferation  is  pre- 
vented) does  not  differ  materially  from  the  original  development  of  the  tissues  in 
embryo,  the  vast  importance  of  asepsis  is  evident,  and  while  cleanliness  is  not  all 
that  is  necessary  to  secure  the  best  possible  result  in  the  healing  of  a  wound,  it  is 
of  sufficient  importance  to  deserve  the  most  careful  consideration. 

It  follows  that  not  only  should  the  atmosphere  of  the  room  and  all  materials 
brought  in  contact  with  the  wound  be  germ-free,  but  that  the  operator  and  all 
assistants  should  carefully  sterilize  the  hands  and  prevent  the  possibility  of  infec- 
tion from  their  person  or  clothing. 

In  cleansing  the  hands  the  nails  should  be  trimmed  closely,  and,  even  if  short, 
should  always  l^e  freshly  clipped.  Three  basins,  which  have  just  been  taken  from 
boiling  water  and  placed  on  a  table  covered  with  a  sterile  cloth,  should  be  filled 
with 

a — 1-1000  mercuric-chloride  solution,  colored  hliie  to  prevent  error.^ 

h — Water  that  has  been  boiled,  or  warm  sterile  salt  solution   (one  tablespoonful 

of  salt  to  one  pint  of  water). 
c — Clear  water  that  has  been  boiled  and  is  quite  warm,  soft  soap  that  has  just 

been  boiled  and  allowed  to  cool,  and  a  brush  and  nail  cleaner  taken  from  the 

boiler  for  each  basin. 

Soak  the  hands  for  several  minutes  in  the  soap-and-water  solution,  rubbing 
them  and  the  forearms  thorotxghly  ^ith  the  lathered  brush,  rinse  and  brush  in 
the  sterile  salt  solution,  and  cleanse  thoroughly  beneath  the  nails  with  a  cleaner. 
Brush  the  hands  again  in  the  soap-and-water  solution,  then  in  the  sterile  salt 
solution,  and  next  soak  them  from  three  to  five  minutes  in  the  1-1000  mercuric 
chloride.  This  being  done,  it  is  advisable  until  the  operation  is  commenced  to 
protect  the  hands  at  once  from  accidental  contact  with  an  unsterilized  material  by 
putting  on  a  pair  of  sterile  hop-picker's  gloves.  Tight-fitting  ntblser  gloves  of 
smooth  or  rough  surface,  which  may  be  thorotighly  sterilized  by  boiling,  are  a  valu- 
able addition  to  modern  teclinic.  It  is  my  preference  to  wear  these  as  a  protection 
to  the  hands  imder  septic  conditions  and  to  use  the  hands  free  in  clean  surgery.  To 
the  general  practitioner,  who  of  necessity  frequently  subjects  his  hands  to  con- 
tact with  infectious  material,  it  is  advisable  to  use  sterilized  rubber  gloves  in 
all  operative  work.  Once  in  contact  with  septic  material,  these  should  be  thor- 
oughly washed  on  both  sides,  first  under  running  warm  water  and  then  with 
brush  and  soap  and  warm  water,  and  finally  boiled  by  being  placed  in  tepid  water 
gradually  heated  to  the  boiling  point.  Upon  cooling  sufficiently  they  should  be 
wrapped  in  a  sterile  towel  and  put  aside,  to  be  boiled  again  just  before  the  next 
operation. 

The  operator  and  first  assistant  should  be  protected  with  a  clean  rubber  apron 
and  over  this  a  full-length  sterile  operating  gown,  preferaljl}'  with  long  sleeves, 
coming  within  eight  inches  of  the  wrist. 

If  they  be  bearded  or  mustached,  these  and  the  face  and  hair  should  he  ren- 
dered aseptic  by  bathing  in  1-1000  mercuric-chloride  solution. 

The  hair  should  be  covered  with  a  sterile  cap,  and  in  all  serious  operations  it 
is  advisable  to  wear  a  veil  of  gauze  over  the  nose,  mouth,  and  beard.  Every  few 
minutes  during  the  operation  the  surgeon  should  rinse  his  hands  with  a  1-1000 
mercuric-chloride  solution,  wiping  them  dry  ■«'ith  a  sterile  towel  before  touching 
the  wounded  surfaces.  This  practice  protects  both  patient  and  surgeon  from 
infection. 

Should  the  operator  be  especially  susceptible  to  the  irritation  of  the  merctiric 
solution,  it  may  be  weakened  to  1-2000  or  1-3000.  All  material  brought  in  contact 
with  or  near  the  wound  should  be  absolutely  sterile. 

1  One  grain  to  one  ounce  is  approximately  1-500.  One  commercial  tablet  to  one  pint  of 
warm  water  is  1-1000. 


A   SURGICAL   OPERATION 


When  a  large  steam  sterilizer  is  not  available,  the  small  one  shown  in  Fig.  1 
may  be  substituted.     A  supply  of  gauze,   towels,   sheets,   etc.,   can  be   sterilized 

in  this  apparatus,  and  trans- 
ported in  the  metal  box  with- 
out being  opened.  In  an 
emergency,  boiling  in  any 
clean  vessel  will  thoroughly 
sterilize  all  cloth  material, 
which  sliould  be  immediately 
wrapped  in  clean  sheets  or 
towels  and  kept  from  expo- 
sure to  dust.  Absorbent  cot- 
ton cannot  be  boiled,  but  can 
l)e  sterilized  in  steam  or  by 
dry  heat.  It  is  more  con- 
venient to  obtain  this  from  a 
reliable  manufacturer.^ 


Fig.   1. — Combination  sterilizer  with  portable  metal  dressing- 
liolders. 


Fig.  2. — Coal-oil  emergency 
boiler. 


Ligatures  and  sutures  are  animal,  vegetable,  and  metallic.  Of  the  former, 
catgut  and  the  tendons  of  the  kangaroo  or  other  animals  are  most  important. 
Horsehair  is  very  useful  in  securing  the  perfect  adjustment  of  the  edges  of 
incisions  upon  the  face  and  other  exposed  surfaces.  Horsehair  is  prepared  by 
washing  thoroughly  several  tiiues  a  day  for  two  or  three  days  in  sterile  soap  and 
water,  and  then  soaking  for  twenty-four  hours  in  1-1000  mercuric-chloride  solu- 
tion. After  this  it  should  be  boiled  for  three  or  four  minutes,  and  then  kept  in  a 
solution  of  alcohol  60  j)arts,  water  40,  and  crystal  iodine  1  part. 

'  1.  In  the  sterilization  of  gauze,  cotton,  towels,  sheets,  etc.,  these  should  be  placed  in  a 
steam-pressure  sterilizer,  and  after  the  door  is  closed  and  the  steam  turned  on,  the  outlet  should 
be  opened  so  as  to  permit  the  escape  of  air.  The  steam  jjressure  should  then  be  raised  to  between 
twenty-three  and  thirty  pounds,  when  an  outlet  in  front  of  the  sterilizer  should  be  opened 
sufficiently  to  allow  the  steam  to  escape  in  a  quantity  not  greater  than  the  amount  being  generated 
in  the  jacket.  This  gives  a  continuous  circulation  of  steam  at  the  above  pressure,  which  should 
be  maintained  from  one  half  to  one  hour  and  is  much  more  efficacious  than  the  same  pressure 
without  circulation. 

2.  Linen,  silk,  silkworm  gut,  horsehair,  and  silver  wire  may  be  sterilized  in  the  steam  steril- 
izer with  the  dressings,  or  wrapped  in  gauze  and  boiled  with  the  instruments. 

3.  In  preparing  chromic-acid  catgut,  the  simplest  way  is  to  soak  the  catgut  in  chloroform 
or  ether  for  a  month,  wind  it  loosely  on  the  spools,  and  let  it  soak  for  twenty-four  hours  in  a  one- 
per-cent  solution  of  chromic  acid  in  water,  after  which  the  spools  may  be  rinsed  in  sterile  water 
and  the  catgut  further  sterilized  as  for  plain  gut  as  directed  by  Dr.  Moschcowitz. 


A  SURGICAL  OPERATION  5 

Silkworm  gut  (preferably  d3-ed  black)  is  one  of  the  cleanest,  strongest,  and 
best  materials  for  closing  skin  incisions,  and  is  much  less  apt  to  invite  infection 
from  the  staphylococcus  epidermidis  albits  than  any  other  non-metallic  suture. 
This  material  is  sterilized  by  boiling,  and  is  kept  in  the  same  solution  in  which  the 
sterilized  horsehair  is  preserved. 

Irish  linen,  plain  or,  preferably,  coated  with  celluloid  Or  gutta-percha  and  dyed 
black,  is  the  best  of  the  vegetable  fibers,  and  has  almost  superseded  silk — No.  50 
for  intestinal  suture  and  25  for  buried  sutures  in  uniting  aponeuroses.  Silver  wire 
is  now  rarely  employed  except  in  operations  for  the  cure  of  cleft  palate,  in  ununited 
fractures,  and  in  exceptional  cases  of  ventral  hernia  and  vesico-vaginal  fistula. 

For  the  closure  of  the  skin  incision,  where  subdermal  or  buried  sutures  (usually 
kangaroo  tendon  or  chromicizcd  ten-day  catgut)  have  been  employed,  small  metallic 
clamps  (Michel)  may  be  employed.  In  their  application,  care  should  be  taken  not 
to  pinch  the  skin  hard  enough  to  cause  pain  or  pressure-necrosis. 

All  ligature  and  suture  material  should  be  made  and  kept  aseptic  under  the 
immediate  supervision  of  the  responsible  operator  or  an  expert  assistant,  or  pur- 
chased from  a  reliable  manufacturer.  This  is  especially  important  with  animal 
material,  the  preparation  of  which  requires  great  care  and  skill.^ 

In  preparing  catgut  in  large  quantities  the  methods  of  Dr.  Willard  Bartlett  or 
Dr.  A.  V.  Moschcowitz  ma}'  be  followed.  Both,  assure  a  safe  and  strong  material 
which  has  been  thoroughl}^  tried.  The  Bartlett  gut  is  softer  and  somewhat  more 
plial^le  or  threadlike,  and  is  generally  preferred.^ 

The  preparation  of  chromicizcd  catgut  has  been  given  in  a  preceding  foot-note. 

I  The  material  sterilized  in  closed  glass  tubes  by  Van  Horn  and  Sawtell,  of  New  York  City, 
has  gi\-en  perfect  satisfaction  in  the  author's  experience.  In  the  extensi\'e  clinic  of  Drs.  W.  J. 
and  C.  H.  JIayo  the  catgut  prepared  by  the  method  of  Bartlett  is  exclusively  used. 

^  Bartlett's  method.  The  ordinary  commercial  10-foot  catgut  strand  is  divided  into  four 
equal  lengths,  each  of  which  is  made  into  a  little  coil  about  an  inch  and  a  half  in  diameter.  By 
twisting  the  last  free  end  about  four  times  around  this  little  coil,  the  coil  will  maintain  its  shape. 
These  coils  are  strung  like  beads  on  a  thread,  and  hung  in  a  metal  can,  or  beaker  glass  without 
being  allowed  to  touch  the  bottom  or  sides.  They  may  be  suspended  by  carrying  the  two  ends 
of  a  thread  through  a  small  opening  in  a  pasteboard  cover  placed  over  the  receptacle.  The  same 
opening  serves  to  admit  a  thermometer,  which  is  carried  down  exactly  to  the  point  where  its 
mercury  bulb  is  on  a  level  with  the  topmost  coils.  Liquid  petrolatum  is  now  poured  in,  the 
quantity  being  sufficient  to  immerse  the  catgut  and  the  bulb  of  the  thermometer.  The  vessel 
is  set  on  a  pan  of  sand,  under  which  is  placed  a  tiny  gas  flame  of  merely  sufficient  intensity  to 
raise  the  temperature  of  the  oil  to  212°  F.  within  one  or  two  hours.  The  temperatvire  should 
remain  at  about  212°  F.  for  twelve  hours,  when  the  heat  should  be  increased  to  such  an  extent 
that  it  will  run  up  to  300°  F.  in  an  hour.  The  gas  is  then  turned  off,  and  the  temperature  of  the 
oil  allowed  to  retiu-n  to  about  212°  F.  The  pasteboard  cover,  with  the  string  of  coils,  is  lifted 
out,  the  superfluous  oil  allowed  to  drop  off,  and  then  the  thread  is  cut,  allowing  the  untouched 
coils  to  fall  into  the  following  mixture: 

Columbian  spirits,  100  parts. 

Iodine  flakes,  1  part. 

This  catgut  is  now  ready  for  immediate  use,  and  will  keep  for  any  length  of  time.  The  jar 
may  be  opened  any  number  of  times,  so  long  as  a  sterile  instrument  is  used  for  remo\'ing  the 
coils,  since  the  iodine  protects  the  coils  left  behind  from  accidental  contamination.  This  catgut 
is  as  strong  and  as  supple  as  silk,  is  easily  seen  on  account  of  its  color,  will  not  untwist  when 
wet  on  account  of  the  oil  in  it,  and  for  the  same  reason  is  more  than  usually  resistant  to  absorption. 

Dry  iodine  catgut  is  prepared  as  follows  by  the  method  of  Dr.  A.  V.  Moschcowitz,  and  has 
been  used  with  perfect  satisfaction  in  the  extensive  surgical  service  of  Mt.  Sinai  Hospital.  ("  Annals 
of  Surgery,"  May,  1903.) 

The  catgut  just  as  bought  from  the  dealer — i.  e.,  without  removing  the  fat — is  loosely  wound 
on  the  spool,  preferably  in  a  single  layer,  and  tied  at  both  ends  to  prevent  unraveling.  Immerse 
for  eight  days  in  a  solution  of  iodine  one  part,  iodide  of  potassium  one  part,  distilled  water  100 
parts.  This  solution  is  prepared  by  dissolving  the  iodide  of  potassium  in  a  small  quantity  of 
water,  to  which  the  iodine,  previously  finely  pulverized,  is  added,  and  the  whole  diluted  up  to 
one  hundred  parts.  At  the  end  of  eight  days  the  catgut  is  removed  from  the  solution,  and 
preserved  thereafter  dry,  in  a  sterile  vessel,  preferably  in  one  not  exposed  to  the  light. 

The  catgut  thus  prepared  and  kept  is  used  dry,  just  as  it  is  cut  from  the  spool,  and  after 
the  operation  any  unused  catgut  may  be  put  through  the  original  process  and  is  resterili^ed. 

For  one  gallon  of  the  solution,  six  hundred  grains  each  of  iodine,  finely  powdered,  and  an 
equal  amount  of  iodide  of  potassium  is  required,  the  whole  costing  about  fifty  cents. 

It  is  important  to  keep  the  solution  in  well-stoppered  bottles  or  jars,  because  the  iodine  is 
volatile. 

A  good  solution  is  not  purple,  it  should  in  bulk  have  a  deep  brown  almost  black  color;  any 
solutioii  not  corresponding  to  these  physical  requirements  should  be  discarded, 


6 


A  SURGICAL  OPERATION 


This  suture  has  replaced  kangaroo  tendon  to  a  considerable  extent,  but  the  latter 
is  still  preferred  by  more  cautious  operators  as  holding  longer  and  therefore  giving 
greater  security  in  hernia  operations  and  in  uniting  aponeuroses  which  may  be 
subjected  to  post-operative  tension.  In  using  sealed  glass  tubes  containing  liga- 
tures, these  should  he  washed  in  clean  water  and  placed  in  a  solution  of  mercuric 


Fig.  3. — Downey's  combination  operating  table. 

chloride,  1-1000,  from  which  they  are  taken  by  the  assistant  when  the  tube  is  to 
be  broken.  It  is  never  advisable  to  expose  the  ligature  material  any  longer  than 
is  necessary. 

In  addition  to  the  foregoing,  the  aseptic  healing  of  a  wound  in  large  measure 
depends  upon  the  performance  of  the  ojDeration  with  the  least  possible  injury  to 
the  tissues.  Violent  retraction,  unnecessary  tearing  and  bruising,  or  scraping  the 
surface  of  a  wound  with  a  swab  or  sponge  all  tend  to  weaken  the  normal  resistance 
of  the  tissues  and  encourage  the  proliferation  of  any  chance  septic  organisms. 


Fig.  4. — The  same  adjusted  to  the  Trendelenburg  position. 


The  fingers  of  an  assistant  should  never  come  in  contact  with  the  wounded 
surface,  nor  those  of  the  surgeon,  when  an  instrument  may  be  substituted.  For  this 
reason,  in  swabbing,  I  prefer  either  to  use  gauze  swabs  held  in  forceps,  or  large 
swabs  which  cover  the  ends  of  the  fingers,  or  a  roll  of  gauze  which  is  unwound 
as  it  is  needed,  and  rerolled  or  cut  off  as  it  becomes  wet. 

Since  all  pathogenic  organisms  proliferate  in  moist  media,  it  is  essential  that  a 
wound  be  left  as  dry  as  possible.     For  this  reason  it  is  often  safer  to  unite  the 


FlQ.  5. — A  single  operating  room  and  dressing  table. 
7 


8  A  SURGICAL   OPERATION 

various  layers  of  tissues  by  separate  rows  of  sutures  (usually  absorbable),  drying 
each  carefully  before  the  overlying  row  is  inserted,  and  where  there  is  a  thick  layer 
of  fat  this  should  be  a|)proximated  by  one  or  more  separate  rows  of  subcutaneous 
catgut. 

When  the  superficial  sutures  are  tied,  the  skin  is  finally  washed  with  1-1000 
mercuric  chloride  and  dried,  and  the  dressing  (usually  dry  sterile  gauze  reenforced 
with  absorbent  cotton)  adjusted  and  held  with  moderate  compression  until  the 
.  roller-bandage  or  adhesive  strips  are  applied. 

The  operating  room,  large,  warm,  thoroughly  ventilated,  and  well  lighted  with 
side  windows  and  skylight  (as  well  as  the  best  obtainable  artificial  illumination), 
should  be  as  clean  and  free  from  dust  as  possible.  To  precipitate  particles  of 
infection-carrying  dust  from  the  atmospliere  a  steam  spray  is  ideal,  though  not 
absolutely  necessary.  Next  in  order  is  sprinkling  the  floor,  walls,  and  furniture. 
The  author  has  operated  for  years  in  a  public  lecture  room,  where  it  is  impossible 
to  secure  ideal  conditions,  and  yet  by  taking  certain  simple  aseptic  precautions, 
in  the  proximity  of  the  operative  field,  the  infection  of  clean  wounds  is  practically 
unlcnown. 

The  accessories  of  an  operating  room  should  be  of  the  simplest  possible  con- 
struction, and  of  material  that  will  permit  of  boiling  or  scouring  with  very  hot 
water  or  mercuric-chloride  solution,  1-1000.  A  good  strong  operating  table  ^  is 
essential,  preferably  one  of  white-painted  metal  and  glass,  so  constructed  and 
arranged  that  the  patient  ma}'  be  made  to  assume  any  necessary  surgical  posi- 
tion. In  many  procedures  the  Trendelenburg  posture  is  recjuired,  while  in  others 
the  head,  neck,  and  chest  need  to  be  elevated. 

There  should  be  two  or  three  side  tables  of  the  same  or  any  cleansible  material. 
Adjustable  stools  (preferably  metal)  for  the  use  of  the  anesthetist  and  operator; 
a  capacious  irrigator,  with  long  rubber  tube  and  glass  tip  or  pipette,  arranged  for 
adjustment  at  various  heights  to  secure  the  necessary  pressure  in  irrigation ;  basins 
and  bottles  for  solutions;  j)us  and  waste  basins,  etc.,  by  preference  made  of  metal 
and  porcelain-lined  (Fig.  5).  Agate  or  ordinary  commercial  china  ware  vessels 
will  serve  in  an  emergency,  the  essential  being  that  they  shoLild  be  subjected  to 
boiling  before  using.  A  boiling  apparatus  should  be  a  part  of  (or  very  convenient 
to)  every  operating  room.  This  may  be  heated  by  gas,  coal  oil,  or,  preferably,  when 
gas  is  not  obtainable,  by  alcohol,  which  is  now  so  cheap  as  to  justify  its  use  under 
all  conditions.  In  addition  to  the  boiling-water  sterilizer  for  instruments,  towels, 
gloves,  and  other  boilable  material,  a  modern  steam-  and  dry-heat  sterilizer  are 
great  conveniences.     In  their  absence  the  water  boiler  may  be  substituted. 

It  is  well  to  keep  on  hand  certain  solutions  which  may  be  required  for  emer- 
gency work.  Normal  salt  solution,  made  of  sterile  filtered  water  (one  teaspoonful 
of  salt  to  one  pint  of  water)  should  be  kept  in  large  glass  bottles,  with  tight-fitting 
stoppers  of  glass  or  sterile  cotton.  Before  being  used  they  should  be  flushed  with 
warm  or  hot  water  in  order  to  remove  dust.  Mercuric-chloride  solutions  colored 
blue,  1-1000,  2000,  3000,  and  5000,  should  be  kept  on  hand  or  made  as  required. 
For  flushing,  especially  in  aljdominal  operations,  some  surgeons  prefer  pouring 
in  the  warm  salt  solution  from  pitchers  rather  than  the  slower  method  of  the 
irrigator. 

In  the  perfection  of  modern  surgery,  a  tank  of  oxygen  ready  for  use  is  always 
available;  also  a  galvanic  or  galvano-faradic  battery  for  purposes  of  resuscitation; 
one  or  two  h3'podermic  syringes  sterilized  and  ready  for  use  if  needed,  together 
with  whisky  and  tablets  or  solutions  of  morphine,  strychnine,  nitroglycerine,  etc. 
While  these  various  remedies  are  rarely  called  into  use,  they  are  in  occasional 
crises  of  inestimable  value,  and  moreover  tend  to  protect  the  surgeon  in  case  of 
disaster. 

Instruments  should  lie  of  the  very  best  quality,  well  selected,  with  handles 
preferably  of  light  metal  and  large  enough  to  be  grasped  firmly  withaiit  cramp- 

'  The  table  devised  by  Dr.  James  H.  Downey  can  be  adjusted  to  any  surgical  position  and 
combines  with  these,  a  mechanism  for  extension  and  counter  extension  for  the  application  of 
plaster-of-Paris  dressings  to  fractures  of  the  thigh  and  leg  and  the  Sayre  extension  in  fitting  the 
gypsum  jacket  in  Pott's  disease, 


A  SURGICAL  OPERATION  9 

ing.    They  should  be  smooth  and  jjolished,  and  so  constructed  as  not  to  be  injured 
by  boiling.    While  the  character  and  extent  of  his  work  should  guide  every  surgeon 


in  the  selection  of  an  armamentarium,  the  following  list  will  be  found  useful  and 
satisfactory : 

From  six  to  twelve  scalpels,  the  blades  varying  in  length  from  one  to  two  and 
a  half  inches.  Major  amputations  may  be  done  with  these  simple  instruments, 
although  a  longer  amputating  knife  is  preferred  by  some  operators. 


ffflimaiifli 


"TS^ 


Two  curved  hlstuuries,  one  sharp,  the  other  j)robe  jjointed,  with  three  and  one 
half  inches  of  ciittinsr  edge. 


The  Kny-scheeker  Co.,  N.  y. 
Fig.  11. 


For  the  subcutaneous  division  of  a  tendon  or  fascia,  a  sharp  and  a  dull-pointed 
instrument  (Pigs.  6  and  7),  while  those  for  cleft  palate  are  illustrated  in  Figs.  8, 


9,  10.^     All  knives  should  be  in  metal  boxes  and  firmly  held  to  jn-otect  the  points 
and  cutting  edges,  and  in  which  they  may  be  boiled  (Fig.  11). 

'  These  illustrations  are  made  from  instruments  in  the  author's  general  operating  case, 
The  name  of  the  maker  appears  only  in  the  engraving. 


10 


A  SURGICAL  OPERATION 


Reiractors  should  be  long  enough  to  keep  the  hands  of  assistants  well  away 
from  the  wound. 

An  excellent  improvised  retractor  may  he  made  of  a  strong  silk  or  linen  thread 
inserted  through  the  tissues  at  the  edges  of  the  woiind,  and  held  by  assistants 
two  or  three  feet  distant. 


Metal  retractors  should  have  two  or  more  sharp  and  dull  prongs,  or  a  broader 
surface  bent  on  the  flat  (Figs.  11,  12,  and  13). 

The  tenaculum  and  aneurism  needle  (Figs.  14  and  15)  are  often  employed  for 
retraction. 


For  general  use  the  bow-saw  (Fig.  16)  -H'ill  meet  all  ordinary  requirements. 
The  l-eyliole  saws  (Fig.  17)  may  be  at  times  needed  for  minor  work,  while  the 
Gigli  steel  tvire  saw  is  essential  in  osteoplastic  operations  on  the  skull. 


Fig.   16. — Bow-saw,  «iili  two  blades. 

A  number  of   different  shajDed   chisels  are   required    for   cutting  or  dividing 
bones  in  the  correction  of  deformities.     Vance's  osteotome   (Fig.  18)   is  an  excel- 


■Tlie  autIior'.s  adjustable  keyhole  saws. 


lent  instrument,  and  in  its  use  requires  a  fairly  heavy  metal  or  hardwood  mallet. 
In  osteomyelitis,  for  exposing  the  medullary  canal,  the  author  uses  by  preference, 
the  ordinary  curved  joiners'  or  sash-makers'  chisel,  with  wooden  handles.     They 


A  SURGICAL   OPERATION 


11 


are  cheap,  durable,  easily  sterilized  by  boiling,  and  can  be  readily  obtained  in  all 
required  sizes. 


Fig.   is. — Vance's  osteotome. 


Volkmann's  sharp  spoons  (Fig.  19),  for  scraping  the  diseased  surfaces  of  bone, 
are  invaluable.     Thev  should  be  in  two  or  three  sizes,  the  middle  one  of  which 


Fig.   19. — Volkmann's 


should  be  very  long  in  the  shank  for  curetting  the  long  bones  in  cases  of  ampu- 
tations for  osteomyelitis. 

Sayre's  periosteal  hnife.  (Fig.  20),  and  a  smaller  sharp  periosteal  elevator  are 
needed,  while  for  cleft-palate  operations  Brophy's  periosteotomes  are  indispensable. 


Fig.  20. — Sayre's  periosteal  elevator. 


Drills  of  small  size  are  necessary  in  wiring  fractures;  in  an  emergency  a  shoe- 
maker's awl  will  suffice.  For  extensive  work  a  drilling  machine  should  be  em- 
ployed. 


G-TIEMANN 1  c^ 

Fig.  21. 


Fig.  21  represents  a  useful  instrument  for  Ijone-cutting  on  the  flat,  while  the 
rongeurs  shown  in  Figs.   23   and  23  are  of  value,  especially  in  operations  upon 


the  cranium.    For  troughing  in  the  trap-door  operation  on  the  skull,  the  De  Vilbiss 
instrument  shown  in  Fig.  24  is  useful. 


12 


A  SURGICAL   OPERATION 


Fig.  25  represents  an  excellent  holding  or  sequestrum  forceps. 

In  trephining,  the  dura  may  be  exposed  by  the  careful  use  of  a  small  sharp 
curved  chisel  and  light  mallet,  although  tlae  trephine  (Fig.  26)  is  more  satis- 
factory. 

Gait's  instrument  has  a  conical  burr  five  eighths  of  an  inch  in  diameter  at  the 
cutting  edge,  gradually  enlarging  to  seven  eighths  at  the  base.    It  is  so  constructed 


that  as  soon  as  resistance  in  front  ceases,  the  side  teeth  take  hold  so  greedily  that 
further  rotation  is  difficult,  and  the  o]ierator  is  thus  warned  that  the  dura  has 
been  reached.  Undue  force  will,  however,  injure  this  membrane.  In  its  employ- 
ment, the  central  bit  should  be  advanced  about  one  eighth  of  an  inch  beyond  the 
level  of  the  teeth,  so  as  to  fix  and  steadv  the  instrument  in  the  bone  rmtil   a 


Fig.  26. — Gait's  treiihine. 


well-marked  circle  is  cut.  The  bit  is  then  withdrawn,  as  the  trephine  can  be  held 
in  place  in  the  circular  trench  already  made.  In  osteoplastic  operations  on  the 
skull  where  rapid  work  is  necessary  a  machine  trephine  is  very  desirable. 

In  controlling  hajmorrhage,  the  flat  elastic  Esmarch  bandage  or  rubber  tubing 
may  be  employed.  For  squeezing  the  blood  out  of  an  extremity  this  apparatus 
is  invaluable.  For  simple  constriction,  the  plain  rubber  tube  is  preferable,  although 
the  Esmarch  may  be  used  for  both.  The  danger  of  injuring  nerves  and  producing 
paralysis  by  too  strong  constriction  should  not  be  overlooked. 

Hcemostatic  Forceps. — The  scissor-handle  clamps  of  various  sizes  and  shapes 
(Fig.  27)  are  in  general  use.  An  operating  outfit  should  have  from  twelve  to 
twenty-four  of  these,  also  dissecting  forceps  with  moiise-tooth  and  corrugated  points. 
The  author's  suture  forceps,  with  perfectly  smooth  and  non-cutting  point,  is  useful 
for  holding  the  first  knot  of  a  suture  or  ligature  immovable  iintil  the  second  knot 
is  tied.  A  needle-holder,  one  or  two  of  the  best  modern  patterns,  should  be  had, 
and  should  be  constructed  to  hold  any  size  or  shaped  needle,  from  the  very  smallest 
curved  instrument  to  the  large  square  Haa'cdorn.^  Scissors  curved  on  the  flat, 
and  dull  pointed,  and  others  fashioned  straight,  are  very  necessary.  Much  cutting 
and  practically  all  dry  or  dull  dissection  may  be  done  with  the  scissors.  Some 
of  these  should  be  long,  others  short.  Proles  of  malleable  material,  preferably 
silver,  of  various  sizes  and  dull  pointed,  are  required,  and  there  should  be  a  grooved 
director  of  the  same  material.  Other  instruments  for  special  operations  will  be 
given  later. 

'  The  p,uthor's  combination  needle-holder  and  Reichert's  are  in  general  use. 


A  SURGICAL  OPERATION 


13 


Every  oijerating  set  should  have  one  or  two  razors  for  preparing  the  skin  of 
the  operative  field. 

All  instniments  to  be  used  in  an  operation  should  be  boiled,  and  when  taken 
from  the  boiler  laid  upon  and  covered  with  sterile  towels.  Occasionally  throughout 
an  operation  they  should  be  dipped  in  hot  sterile  water. 

Dressings. — The  ordinary  dressings  are  made  of  gauze  and  cotton,  covered  over 
at  times  with  ruljber-tissue  protective  or  oiled  silk.  Plain  gauze  is  made  of  cotton 
cheese-cloth,  is  absorbent,  and  should  be  in  sterilized  packages.  It  is  used  now 
altogether  for  sponging,  having  entirely  displaced  the  sea  sponge  formerly  em- 
ployed. When  it  has  been  exposed,  it  should  be  resterilized  before  using,  either 
in  wet  steam  or  by  being  boiled  for  twenty  minutes,  then  wrung  out  and  kept  in 
sterile  sheets  or  towels  for  drying.    It  may  at  times  be  used  when  moist. 

While  it  is  advisable  to  purchase  these  various  materials  from  reliable  manu- 
facturers, in  an  emergency  it  may  be  prepared  as  follows :  Take  a  bolt  of  cheese- 


FiG.  28. — Ribbon  of  gauze 
in  sealed  tube  for  wick- 
drainage  or  deep  paclving. 


cloth  and  cut  it  into  pieces  one  or  two  yards  long ;  place  in 

boiling  water  for  two  or  three  hours;  rinse  in  cold  water 

and  soak  in  liquor  sodii  chlorinate    (one  part  to  five  of 

water)  for  twenty-four  hours.     Rinse  again  in  clear  water 

and  fold  the  gauze  away  in  towels  in  a  clean  drawer.    When 

about  to  use  the  gauze  for  a  dressing  it  is  placed  in  a 

sterilizer  and  boiled.     If  a  dry-heat  sterilizer  is  at  hand,  it  should  be  placed  in 

that  and  subjected  to  a  high  degree  of  heat. 

Mercuric  chloride  gauze  is  no  longer  used  as  a  dressing.  lodoformized  gauze 
is  rarelj'  employed,  except  in  certain  packings  in  the  pelvis  after  operations  through 
Douglas'  cul-de-sac  for  the  relief  of  pelvic  peritonitis.  It  should  be  made  of  cheese- 
cloth and  impregnated  with  iodoform  in  crystals,  and  sterilized  by  a  reliable  manu- 
facturer.    It  is  best  carried  in  metal  tubes  (Fig.  28). 

Ahsorient  cotton-  is  so  difficult  of  preparation  that  the  practitioner  is  obliged 
to  purchase  it  as  prepared  for  the  market.  It  can  he  sterilized  in  the  dry-heat  or 
wet-steam  sterilizer.  This  material  forms  such  an  important  part  of  surgical  dress- 
ings that  it  should  be  prepared  with  great  care.  None  should  be  used  that  has  not 
been  submitted  to  thorough  sterilization  after  manufacture. 

A  very  convenient  dressing  for  any  general  ojierative  wound  is  made  of  about 
twelve  layers  of  sterilized  gauze,  in  squares  or  parallelograms  to  suit  varying  con- 
ditions, and  over  this  one  layer  of  absorbent  cotton,  and  over  this  one  layer 
of  cheaper  cotton-batting.  It  is  very  exceptional  that  rubber-tissue  protective  or 
oiled  silk  is  used.  'Wlien  a  wet  or  moist  dressing  is  applied,  this  covering  is 
advisable. 


14  A  SURGICAL  OPERATION 

Rubber  tissue  should  be  kept  in  a  cold,  dry  place,  and  slioidd  be  submerged  in 
1-1000  bichloride  solution  one  hour  before  it  is  used  in  contact  with  an  exposed  or 
abraded  surface.  It  is  yctj  rarel}^  applied  next  to  the  skin,  except  as  a  dressing 
for  burns  or  in  Thiersch  grafts. 

For  the  drainage  of  wounds,  catgut  and  soft  sterile  rubber  tubing  are  in  general 
emplo3'ed.  An  ideal  catgut  drain  is  made  by  placing  parallel  with  each  other  13 
to  30  or  40  strands  of  No.  3  or  No.  3  catgut,  using  plain  or  chromicized,  owing  to 
the  length  of  time  that  drainage  may  be  required,  the  plain  for  one  or  two  days 
and  the  ten-da}'  chromic  gut  for  the  longer  drainage.  It  is  better  to  arrange  these 
in  bundles,  the  strands  parallel  rather  than  twisted,  as  twisting  interferes  with 
their  capillarity.  Eubber-tube  drains  may  be  used  for  the  gall  ducts  or  the  urinary 
bladder.  For  jDeritoneal  drains,  soft  rubber  tubes,  varying  in  diameter  from  one 
fourth  to  as  much  as  an  inch  or  more,  are  invaluable.  The  smaller  drains  are 
preferable.  They  are -prepared  by  splitting  the  tube  from  end  to  end  either  in  a 
^  straight  line  or  spirally.  Wilhin  the  lumen  of  the  tube  a  loose  wick  of  sterile  gauze, 
which  should  not  more  than  half  fill  the  cavity  of  the  tube,  is  placed.  The  gauze 
should  not  come  nearer  than  one  fourth  of  an  inch  from  the  inner  end  of  the  tube. 
Outside  the  tube  is  loosely  wrapped  with  two  or  three  layers  of  gauze,  and  over 
this  a  layer  or  two  of  rubber-tissue  protective.  The  peritona;um  and  the  intestines 
do  not  adhere  to  the  rubber  tissue,  wliich  makes  the  removal  of  the  tube  painless 
and  easy.  A  cigarette  drain  is  made  by  wrapping  a  loosely  rolled  ribbon  of  ab- 
sorbent gauze  in  three  or  four  layers  of  rubber-tissue  protective. 

In  .using  these  tubes,  especiallj^  in  gall-bladder  and  gall-duet  operations,  in 
order  to  hold  the  end  of  the  tube  at  the  proper  drainage  point  it  is  often  necessary 
to  fasten  the  rubber  to  any  convenient  tissue  by  a  small  No.  0  or  No.  1  plain 
catgut  suture.  This  prevents  accidental  displacement  as  the  dressing  is  being 
applied  and  the  patient  piTtto  bed.  Within  thirty-six  hours  the  suture  softens  and 
the  tube  may  be  withdrawn. 


■     CHAPTER    II 

ANAESTHESIA 

GEJTERAL  COXSIDERATIOlSrS — ^ETHER,   CHLOEOFORM,  NITROUS  OXIDE,   COCAIITE,   QUIiSTIA 
AND   UEEA^   RECTAL   AN.ESTHESIA^   AND    SPINAL   ANALGESIA 

While  no  anfesthetie  is  absolutely  safe,  with  a  proper  knowledge  of  the  effects 
of  the  various  agents  upon  the  tissues  in  health,  and  especially  in  disease,  together 
with  a  careful  study  of  the  conditions  of  the  tissues  at  the  time,  and  always  pre- 
suming that  the  patient  has  ieen  properly  prepared  and  that  the  administration  is 
in  the  hands  of  an  experienced  and  careful  anasihetist,  the  danger  is  exceedingly 
slight.! 

In  the  effort  to  condense  in  the  smallest  possible  space  the  essentials  of  surgical 
practice  as  accepted  by  the  author,  there  will  only  be  considered  ether,  chloroform, 
nitrous  oxide,  cocaine,  and  quinia  and  urea. 

The  full  measure  of  the  benefit  of  surgery  to  mankind  will  never  be  realized 
until  the  science  and  art  of  anaesthesia  are  more  thoroughly  understood  and  more 
skillfully  practiced.  Knowing  that  the  danger  to  life  under  proper  conditions  is 
infinitesimal,  and  that  almost  all  the  disagreeable  features  connected  with  anaes- 
thesia as  at  present  induced — namely,  the  natural  dread  of  suspended  conscious- 
ness, the  anxiety  or  fright,  and  the  distressing  sense  of  suffocation,  together  with 
the  equally  annoying  and  perplexing  after-eflfects — may  be  avoided,  there  is  made 
a  sad  confession  of  the  crudeness  of  our  art  and  the  necessity  for  its  improvement. 

Surgery  can  never  reach  that  millennium  toward  which  the  eyes  of  all  must 
turn  who  feel 

That  touch  of  nature  which  makes  the  whole  world  kin, 

when  all  in  physical  distress  will  seek  relief  when  their  trouljles  are  Just  com- 
mencing and  when  they  are  safely  and  easily  remedialjle,  until  anaesthesia  is  roblDed 
of  its  present  well-founded  and  wideh'  felt  distrust.    The  essentials  to  this  end  are : 

1.  A  knowledge  of  the  effects  of  the  various  agents  employed  upon  the  organs 
and  tissues  in  health  and  in  disease. 

2.  A  knowledge  of  the  condition  of  the  organs  and  tissues  at  the  time  of 
administration. 

3.  A  careful,  systematic  preparation  of  the  patient. 

4.  A  trained  anesthetist,  suffieientlj^  cautious  and  relialjle  to  entirely  relieve 
the  operator  of  all  the  responsibility  as  to  the  narcosis. 

Heretofore  the  agents  almost  exclusively  employed  have  been  ether  and  chloro- 
form. Speaking  entirely  from  the  standpoint  of  the  clinician  (without  regard  to 
laboratory  deductions),  it  is  known  that  the  vapor  of  ether  or  chloroform  in  the 
blood,  even  in  small  quantity,  lowers  the  normal  resistance,  and  is  capaljle  of 
serious  injury  to  the  tissues.  Both  are  irritants  to  the  respiratory  organs  in  the 
process  of  administration,  and  to  the  kidneys  in  the  process  of  elimination,  and 
of  the  two,  ether  is  more  capable  of  injury  to  these  organs.  On  the  other  hand, 
chloroform,  at  times  and  under  conditions   which  the  most  careful  preliminary 

'  Reference  is  made  to  a  most  instructive  paper  by  the  late  Dr.  Ernest  J.  Mellish,  of  El  Paso, 
Texas,  which  was  read  at  the  Fifty-fourth  Session  of  the  American  Medical  Association,  pub- 
lished in  the  Journal  of  that  organization  December  5,  1905,  et  seq. 

15 


16  ANESTHESIA 

study  may  not  reveal,  exerts  an  alarming  and  occasionally  fatal  influence  upon  the 
heart.  This  is  especially  true  as  regards  children.  The  author  has  had  two  sudden 
deaths,  both  in  the  first  stage  of  chloroform  inhalation,  when  the  anfesthetic  was 
being  administered  with  all  possible  caution  and  by  an  experienced  anaesthetist. 
He  has  knowledge  of  four  other  cases  in  children  who  died  from  this  anaesthetic, 
and  all  but  one  in  the  first  stage  of  its  administration.  As  between  these  two  agents, 
it  should  follow  that  in  weak  heart  action,  due  to  atheroma  of  the  coronary  arteries 
or  to  fatty  degeneration  of  the  heart  muscle,  or  in  subjects  who  have  had  repeated 
attacks  of  rheumatism,  or  with  chronic  valvular  lesions  of  the  heart,  ether  or 
some  other  anEesthetic  should  be  preferred  to  chloroform.  Upon  the  other  hand, 
when  nephritis  is  present,  especially  in  an  acute  form,  or  when  a  patient  has  had 
any  recent  inflammatory  lesion  of  the  kidney,  as  between  ether  and  chloroform 
the  latter  is  preferable,  provided  always  that  the  condition  of  the  heart  does  not 
contra-indicate  the  employment  of  chloroform.  In  laryngitis,  bronchitis,  pulmo- 
nary emphysema,  extensive  pleuritic  effusion,  with  or  without  adhesions,  and  in 
patients  who  have  chronic  pneumonia  or  any  consolidation  of  the  lung  due  to 
tuberciilosis  or  gumma,  chloroform  should  be  preferred  to  ether,  provided  that  the 
condition  of  the  heart  will  justify  its  use,  and  always  provided  that  analgesia  or 
ancesthesia  may  not  be  secured  hy  some  other  means  less  injurious  to  the  organs 
than  either. 

Formerly,  in  operations  within  the  peritoneal  cavity,  there  being  no  positive 
contra-indications,  chloroform  was  preferred  for  the  reason  that  during  and  after 
the  operation  vomiting  was  less  apt  to  occur.  It  has,  however,  been  demonstrated 
that  the  disagreeable  after-effects  of  ether,  as  well  as  chloroform,  may  be  greatly 
lessened  by  combining  with  ether  nitrous-oxide  gas  and  oxygen  in  certain  propor- 
tions, and  thus  diminishing  the  quantity  of  the  more  noxious  vapor. 

It  has  also  been  demonstrated  that  a  prolonged  and  satisfactory  narcosis  can 
be  induced  and  maintained  by  the  combination  with  ether,  of  morphia  hypoder- 
mically,  and  nitrous-oxide  gas  and  oxygen,  together  with  the  mechanical  induction 
of  cerebral  anajmia  by  Professor  Dawbarn's  method  of  temporarily  confining  a  good 
portion  of  the  volume  of  blood  in  the  extremities.  In  expert  hands,  after  the  nar- 
cosis is  once  complete,  operations  lasting  an  hour  or  more  have  been  performed 
with  the  anffisthetie  discontinued,  the  patient  seemingly  in  natural  sleep. 

As  before  stated,  in  children  ether  is,  in  general,  safer  than  chloroform,  and 
this  without  regard  to  the  greater  irritation  of  the  resj)iratory  tract  from  ether. 

Patients  with  atheroma  of  the  blood  vessels,  especially  when  this  condition  of 
arteritis  has  been  due  to  prolonged  alcoholic  addiction,  take  any  anaesthetic  badly, 
and  in  these  subjects  local  anaesthesia  is  always  to  be  employed  when  possible. 
The  same  is  true  in  lesser  degree  of  very  fat  subjects,  who  are  generally  of  low 
resistance. 

In  an  emergency,  where  it  becomes  necessary  to  perform  an  operation  within 
one  or  two  hours  after  the  ingestion  of  a  quantity  of  solid  food,  if  local  anaesthesia 
is  not  possible  and  only  chloroform  and  ether  are  at  hand,  the  former  may  he 
given  preference,  since  per  se  it  is  less  apt  to  induce  vomiting.  Under  such  con- 
ditions it  is  advisable  to  practice  gastric  lavage. 

Chloroform  has  been  found  so  safe  in  obstetrical  practice  that  by  common 
consent  it  is  emploj'ed  in  parturition. 

When  an  experienced  assistant  cannot  be  had,  there  being  only  ether  and 
chloroform  available,  the  former  should  be  employed  for  the  reason  that  an  un- 
trained anassthetist  is  capable  of  less  harm  with  it  than  with  chloroform. 

When  we  realize  that  the  accepted  death-rate  from  chloroform  is  about  one  in 
two  thousand  administrations,  and  from  ether  about  one  in  five  thousand,  we  must 
appreciate  the  necessity  of  not  using  these  agents  when  safer  methods  are  possible, 
or  of  endeavoring  to  secure  the  necessary  anaesthesia  by  using  smaller  quantities  of 
these  more  powerful  agents  which,  in  combination,  may  not  only  be  made  less 
dangerous  to  life,  but  less  objectionable  in  their  after-eifects.^     The  storm-center 

'Mellish  quotes  Bouffleur's  statistics,  of  over  1,000,000  chloroform,  and  500.000  ether 
ansesthesias,  with  a  mortality  of  1  in  3355  for  the  former  and  1  in  16,768  for  the  latter.  As 
employed  up  to  within  a  recent  period,  in  the  author's  opinion,  the  death-rate  was  greater  than 


ANESTHESIA  17 

of  major  surgery  is  the  alimentary  canal,  and  every  clinician  knows  that  even 
small  quantities  of  ether  or  chloroform  have  a  deleterious  effect  upon  the  secretions 
of  the  digestive  apparatus,  weakening  if  not  paralyzing  the  muscle  of  the  intes- 
tinal wall,  and  on  this  account  interfering  materially  with  the  comfort  and  the 
recuperative  power  of  the  patient. 

Even  nitroiis  oxide  should  not  be  carelessly  or  indiscriminately  given.  He^nitt 
reports  seventeen  deaths  from  this  agent,  while  cocaine,  even  in  weak  solutions 
and  in  the  hands  of  experts,  by  reason  of  idiosyncrasy  or  special  susceptibility,  has 
frequently  produced  alarming  and  occasionalh^  fatal  results. 

There  is  an  agent,  nitrous-oxide  gas,  which,  administered  with  the  free  admix- 
ture of  air  or  oxygen  (of  the  former  fifteen  to  eighteen  per  cent,  and  of  the  latter 
five  to  eight  per  cent — Gwathmey),  is  practically  without  danger;  and  so  few  are 
the  disagreeable  features  connected  with  its  administration  that  even  timid  children 
can  be  easily  taught  to  submit  to  it  willingly  and,  when  necessar}',  repeatedly.  The 
death-rate  from  nitrous  oxide  is  estimated  at  one  in  from  fift}'  to  one  hundred 
thousand.  With  oxygen  no  deaths  have  been  reported,  and  it  is  held  to  be  safer 
than  the  admixture  with  air.  It  may  be  used  to  the  exclusion  of  chloroform 
or  ether  in  a  large  number  of  procedures  which  heretofore  have  reqtured  these 
agents.  TTith  nitrous  oxide  the  frequently  repeated  passive  motion  so  essential  to 
success  in  the  treatment  of  certain  fractures  communicating  with  the  joints  (more 
particularly  of  the  elbow)  may  be  made  with  the  best  possible  results.  In  the 
prevention  of  ankvdosis  in  all  forms  of  joint  involvement  it  is  of  inestimable  value, 
for  the  reasons  that  it  is  safe,  the  narcosis  is  induced  in  a  minute  without  a  disagree- 
able sensation,  entire  consciousness  is  restored  within  a  minute  after  its  discon- 
tinuance, and  there  is  not  a  suggestion  of  nausea  or  unpleasantness ;  and.  most 
important  of  all,  patients  will  not  hesitate  to  repeat  it  as  often  as  necessary  to 
secure  the  best  possible  results. 

In  the  setting  of  minor  fractures,  where  muscular  rigidity  is  not  extreme,  it 
can  be  used  to  great  advantage  and  with  the  minimum  of  inconvenience.  However, 
in  all  fractures  of  the  thigh  and  near  the  hip,  or  elsewhere,  when  complete  muscular 
relaxation  is  essential  to  the  successful  reduction  and  maintenance  of  the  parts 
in  apposition  until  the  plaster-of-Paris  fixation  dressing  can  be  hardened  in  place, 
the  more  profound  narcosis  of  ether  is  essential. 

A  long  list  of  minor  surgical  procedures  where  cocaine  infiltration  is  not  done, 
such  as  the  extraction  of  teeth,  removal  of  adenoids,  incision  of  an  abscess,  felon, 
pleural  empyema  with  resection  of  one  or  more  ribs,  fistula  in  ano.  fissure,  isolated 
hffimorrhoids,  in  all  short  exploratory  operations  of  the  abdomen,  suprapubic  cys- 
totomy, nephrotomy,  strangulated  hernia,  minor  amputations,  moderate-sized  tu- 
mors, and  all  minor  and  many  other  major  procedures  where  complete  muscular 
relaxation  is  not  absolutely  essential,  this  agent  may  be  employed  -n-ith  perfect  sat- 
isfaction. Operations  lasting  from  a  half  hour  to  an  hour,  including  colostomy,  gas- 
trostomy, and  enterostomy,  have  been  repeatedly  and  successfully  performed  with 
no  other  agent  than  this  with  the  free  admixture  of  air  or,  preferably,  oxj-gen.^ 

If  at  any  time  in  the  administration  of  this  agent  a  more  complete  temporary 
relaxation  or  quiescence  is  demanded,  a  few  whiffs  of  ether  or  chloroform,  as  may 
be  indicated,  together  with  the  judicious  use  of  Dawbarn's  sequestration,  and  the 
preliminary  injection  of  a  small  quantity  of  morphine  and  atropine  (-J  to  I  gr.  of 
the  former,  yj^  to  -^jt^  of  the  latter),  will  enable  the  surgeon  in  at  least  fifty  per 
cent  of  all  operations  to  dispense  ■nith  the  dangers  and  disagreeable  effects  of  the 
major  auEesthetics,  ether  and  chloroform. 

Xitrous  oxide,  on  account  of  the  persistence  of  the  reflexes  during  its  admin- 
istration, is  at  times  contra-indicated  in  certain  procedures  where  perfect  muscular 
relaxation  is  essential. 

Again,  the  general  profession  has  not  as  yet  shown  a  proper  appreciation  of 

would  appear  from  these  statistics,  but  within  the  last  few  years,  with  improved  apparatus,  the 
employment  of  expert  anesthetists,  and  a  more  careful  selection  of  cases  for  a  given  anEesthetic, 
the  ratio  of  mortality  is  fully  as  low  as  that  given  in  Bouffleur's  statistics,  and  doubtless  will 
be  much  further  reduced. 

1  Arthur  D.  Bevan,  "Trans.  Am.  Med.  Association,"  1907. 


18 


ANAESTHESIA 


the  value  of  local  ansstliesia  as  induced  by  the  skillful  injection  of  cocaine  hydro- 
chlorate  and  quinia.  Practically  all  of  the  minor  operations  and  many  major 
procedures  heretofore  requiring  general  narcosis  may  be  safely  and  satisfactorily 
performed  with  these  agents. 

Ether. — The  vapor  of  ether  is  inflammable,  and  may  possibly  ignite  if  a  flame 
or  cautery  be  brought  too  near  the  inhaler.     It  is  primarily  a  cardiac  stimulant, 


Fig.  29. — Gwathmey's  balloon  inhaler  for  ether  alone  or  nitrous  oxide  and  ether. 

and  increases  arterial  tension.  On  the  nervous  system  it  acts  as  a  paralyzant, 
affecting  first  the  cerebrum,  next  the  cerebellum,  later  the  sensory  and  motor  func- 
tions of  the  cord. 

It  may  be  given  alone  or  in  combination  with  nitrous  oxide.  While  in  an 
emergency  it  may  be  given  by  the  open  or  drop  method,  on  account  of  the  low 
temperature  of  the  vapor  as  thus  inhaled,  which  not  only  acts  as  an  irritant  to  the 


Fig.  30. — Gwathmey's  warm-vapor  apparatus  for  chloroform  or  ether. 


respiratory  tract,  favoring  the  development  of  bronchitis  or  pneumonia,  but  dimin- 
ishes the  body  temperature  and  therefore  weakens  the  normal  resistance,  it  should, 
when  possible,  be  warmed  before  inhalation,  preferably  by  a  thermal  (hot-water) 
apparatus  or  by  one  of  the  closed  or  balloon  methods  in  which  the  expired  air  is 
in  a  measure  used  to  raise  the  temperature  of  the  vapor. 

The  anassthetist  should  have  at  hand   (1)   a  wedge-  or  screw-shaped  piece  of 


ANiESTHESIA 


19 


Wood  or  hard  rubber,  for  forcing  and  holding  the  jaws  apart  (Fig.  31)  ;  a  Sayre 
periosteal  elevator  is  a  good  substitute.  (2)  A  mouth  gag  (Figs.  33-33)  with  which 
to  keep  the  jaws  permanently  open,  if  necessary.      (3)    A  tenaculum  or  forceps 


Fia.  31. — Hard-rubber  oral  screw. 

for  drawing  out  the  tongue  (Fig.  34a).  (-t)  A  large-sized  curved  needle,  armed 
with  a  stout  silk  thread,  for  transfixing  this  organ  should  the  emergency  arise. 

(5)  Forceps,  with  small  sponges  or  swabs  for  mopping  out  the  pharynx  and  throat. 

(6)  A  bottle,  graduated,  so  that  the  exact  quantity  of  the  anaesthetic  taken  is 
known.  (7)  Whisky  or  brandy  for  hypodermic  use.  (8)  A  sterilized  hypodermic 
syringe.  (9)  A  pus  basin  or  pan,  in  case  of  vomiting.  (10)  Towels  to  cover  the 
patient's  face  as  a  guard  against  infection  of  the  operating  wound.  (11)  A  cylinder 
of  oxygen  ready  for  inhalation.     (12)  A  tube  for  the  trachea. "^ 

In  the  administration  of  ether  alone  the  safer  method  is  to  employ  the  thermal 
inhaler  (Fig.  30).     In  this  apparatus  the  ether  vapor  is  forced  out  by  a  hand-ball 


33. — Gross'  speculum  oris. 


pump  through  the  hot-air  chamber,  and  thus  enters  the  respiratory  tract  near  the 
body  temperature.  Should  this  be  unavailable,  the  next  in  order  of  preference  is 
the  Ormsby,  or  some  form  of  inhaler  to  which  a  rubber  balloon  is  attached  (Fig. 
29).  The  expired  air  coming  in  contact  with  the  ether  in  the  balloon  raises  the 
temperature  very  considerably  before  it  passes  into  the  lungs.  The  partial  asphyxia 
which  may  result  from  breathing  over  and  over  again  the  expired  air,  while  more 
objectionable  than  warmed  oxygenated  vapor,  is  not  dangerous,  and  any  symptoms 
of  suffocation  may  be  quickly  relieved  by  tilting  the  mouthpiece  to  one  side  during 
two  or  three  inspirations.  Should  the  pulse,  color,  or  respiration  suggest  it,  the 
necessary  quantity  of  oxygen  may  be  administered. 

Since  the  passage  of  inspired  air  over  ether  vapor  carries  this  into  the  lungs  at 
a  temperature  so  low  that  it  tends  to  excite  irritation,  the  open  air  or  drop  method 
is  only  advised  in  an  emergency  or  under  conditions  which  make  the  thermal 
methods  impossible. 

'  A  galvano-faradic  battery  may  in  very  exceptional  cases  be  of  ser^'ice. 


20 


ANESTHESIA 


In  the  "  drop  "  method,  the  Esmareh  screen,  covered  with  several  additional 
la3'ers  of  gauze  or  a  gauze  mat,  may  be  used.  The  eyes  and  chin  are  protected  by 
towels  or  gauze,  and  the  ether  (preferably  warmed  in  a  basin  of  hot  water),  drop 
by  droT)  in  rapid  succession,  is  made  to  moisten  the  screen. 

The  quantity  of  ether  necessary  for  a  given  operation  will  vary  in  different 
individuals,  but  in  general  it  is  largely  dependent  upon  the  skill  and  experience 


Fig.  34. — Pressing  the  lower  jaw  and  base  of  the  tongue  forward.     (Esmareh.) 

of  the  anjesthetist.  An  operation  lasting  an  hour  should  not  require  more  than 
from  two  to  four  ounces,  especially  when  a  preliminary  injection  of  morphia  and 
atropia  has  been  made. 

Professor  Dawbarn  has  recently  demonstrated  a  method  of  prolonged  narcosis 
with  the  minimum  of  ether,  by  confining  a  portion  of  the  blood  supply  in  the 
lower  extremities  during  the  operation,  in  this  manner  not  only  lessening  the  blood 
pressure  and  hasmorrhage  in  the  wound,  but  at  the  same  time  causing  a  temporary 


cerebral  anaemia,  which  induces  an  almost  natural  sleep.  In  operations  lasting  an 
hour  it  is  possible  to  discontinue  the  an;Esthetic  after  the  first  incision.  Elastic 
bandages  are  wound  around  the  thighs  at  the  crotch,  the  pressure  being  so  adjusted 
that  the  return  of  the  blood  through  the  veins  is  retarded,  while  it  can  still  flow 
out  through  the  arteries.     This  method  is  worthy  of  most  serious  consideration. 

The  anajsthetist  should  always  have  at  least  one  assistant,  and  when  help  is 
scarce,  especially  in  dealing  with  an  alcoholic  subject  or  a  strong,  excitable  patient, 
holding  straps  should  be  thrown  over  the  chest  and  knees  and  around  the  table. 
As  a  routine  practice  this  precautionary  method  of  restraint  is  advised. 

In  order  to  prevent  the  possibility  of  infection  from  the  mouth  and  nose  of  the 
patient,  a  curved  wire  should  be  fastened  to  the  operating  table  at  the  level  of  the 
chin,  and  on  this  a  towel  so  arranged  that  the  face  is  entirely  screened  from  the 
field  of  operation. 

In  the  -first  stage,  of  ether  anaesthesia  the  face  is  usually  flushed,  the  pulse  in- 


ANESTHESIA 


21 


creased  in  force  and  frequency,  and  there  may  develop  a  slight  delirium  from  the 
intoxication.  This  stage  lasts  only  two  or  three  minutes,  when  the  character  of  the 
breathing,  becoming  more  regular,  indicates  that  the  stage  of  excitement  is  passing 
into  the  second  stage,  that  of  relaxation  and  unconsciousness.  The  respiration 
becomes  regular  and  soft,  and  the  corneal  reflex  is  lost.  Should  the  breathing 
become  sonorous  on  account  of  the  base  of  the  tongue  falling  back  upon  the  larynx, 
the  index-linger  inserted  just  beneath  the  angle  of  the  jaw,  pressing  this  gently 
forward  (Fig.  3-1),  lifts.the  tongue  and  permits  the  uninterrupted  ingress  of  the 
anassthetic.  Should  vomiting  occur,  the  apparatus  shoiild  be  removed  to  prevent 
its  being  soiled,  and  immediately  applied  when  the  mouth  has  been  cleansed.  If 
mucus  collects  in  the  nose,  mouth,  or  lar3mx,  it  should  be  removed  with  sponges 
on  holders.  Should  the  patient  turn  blue  suddenly,  the  jaw  should  be  pried  open 
with  a  screw  or  wedge,  and  the  tongue  drawn  forward.  Plenty  of  fresh  air  should 
be  admitted  to  the  room,  and  the  oxygen  tank  (which  it  is  always  proper  to  have 
near  at  hand)  may  be  brought  into  requisition.  In  the  event  of  respiration  being 
entirely  suspended,  artificial  respiration  should  at  once  be  performed. 

Sylvester's  Method. — Slide  the  patient  over  the  end  of  the  table  until  the  head 
hangs  down,  tilt  the  foot  of  the  table  up  by  placing  the  lower  legs  on  a  stool  or 


Fig.  35. — Forcing  the  dead  air  from  the  lungs  by  jDresbUre  upon  tlie  walls  of  the  chest. 

chair.  Stand  at  the  patient's  head,  as  he  rests  upon  the  inclined  plane,  and  seize 
the  arms  at  or  near  the  elbows,  pressing  them  down  upon  the  thoracic  walls,  thus 
forcibly  emptying  the  lungs  (Fig.  35),  and  immediately  thereafter  extending  them 
upward  parallel  with  the  long  axis  of  the  body,  aiding  in  the  expansion  of  the  chest 
(Fig.  36)  ;  this  is  repeated  eight  or  ten  times  a  minute,  and  kept  up  by  relays  of 
assistants,  if  necessary,  until  voluntary  respiration  is  established  or  the  heart  has 
ceased  to  beat.  It  is  important  that  these  manipulations  should  in  no  Avay  inter- 
fere with  the  assistant  who  is  holding  the  tongue  out  of  the  mouth  and  the  gag  in 
place.  If,  in  the  judgment  of  the  surgeon,  the  respiratory  failure  has  been  caused 
by  occlusion  of  the  larynx  or  trachea,  a  rapid  tracheotomy  should  be  done.  The 
insertion  of  a  tracheotomy  tube  is  not,  under  such  circumstances,  advisaljle,  it  being 
safer  to  grasp  the  edges  of  the  incised  trachea  with  tenacula,  or  insert  a  silk  suture 
through  the  skin  and  tracliea  on  either  side  and  hold  the  wound  gaping  while  an 
effort  is  made  to  clear  away  the  obstruction. 

Heart  failure  is  exceedingly  rare  in  ether  narcosis.  A  weak  heart  is,  in  general, 
stimulated.  Occurring  later,  it  is  indicated  by  gradual  weakening  in  the  force  with 
increased  rapidity  of  the  pulse,  or  by  the  rapid  supervention  of  pallor.     One  or  two 


22 


ANAESTHESIA 


drams  of  whisky  or  brandy  may  be  administered  hypodermically,  or  an  ounce  of 
whisky  in  a  half  jjint  of  warm  water  may  be  thrown  into  the  rectum  and  colon. 
In  certain  instances,  where  hfemorrhage  has  been  quite  profuse,  Esniarch's  elastic 
bandage  should  be  thrown  around  the  extremities,  from  the  foot  to  the  hip  and  from 
the  fingers  to  the  shoulder,  in  order  to  force  the  blood  in  them  into  the  general 
circulation.  The  patient's  head  should  be  placed  lower  than  the  body,  by  allowing 
it  to  hang  over  the  upper  end  of  the  table  (Fig.  35)  ;  if  the  heart  should  cease  to 
beat,  striking  sharply  upon  the  ribs  near  this  organ  with  the  palm  of  the  hand, 
at  the  same  time  showering  the  chest  and  epigastrium  with  cold  water  or  ether, 
may  act  as  a  stimulant. 

If  within  a  few  seconds  this  does  not  succeed,  it  is  the  imperative  duty  of  the 
surgeon  rapidly  to  incise  the  chest  wall  in  the  fourth  intercostal  space  near  the 
sternum,  open  the  pericardium,  and  massage  the  heart  between  the  thumb  and 
index-finger.  Several  cases  are  recorded  in  which  resuscitation  has  been  effected 
by  this  heroic  method.  Artificial  respiration  by  Sylvester's  method  and  the  inhala- 
tion of  oxygen  should  be  practiced,  and  when  hajmorrhage  has  been  severe,  the 
rapid  injection  of  salt  solution  in  a  vein  should  be  added. 

If  respiration  alone  ceases,  a  sharp  slap  immediately  over  the  sternum  will 
almost  invariably  cause  the  patient  to  breathe  (Gwathmey).  In  elderly  persons, 
and  in  all  patients  in  whom  for  any  reason  rigidity  persists  with  the  usual  tendency 
to  asphyxia,  it  will  be  advisable  to  change  to  the  warm  ether  drop  method,  adding 
from  time  to  time  a  drop  or  two  of  chloroform,  also  kept  warm  by  placing  the 
bottle  in  a  basin  of  hot  water. 

Great  care  should  be  taken  to  keep  the  ether  inhaler  clean.  After  each  opera- 
tion it  should  be  taken  apart,  cleansed  with  soap  and  brush,  and  submerged  in 


Fig.  36. — Expanding  the  chest  .and  filUng  the  lung.s  with  fresh  air. 


1-1000  or  2000  mercuric-chloride  solution,  or  boiled.  The  infection  of  the  respira- 
tory tract  by  germs  conveyed  from  one  patient  to  another  may  result  if  this 
precaution  be  not  taken. 

Chloroform. — Pure  chloroform  is  more  irritating  to  the  skin  than  ether.  If 
prevented  from  rapid  evaporation,  it  produces  vesication.  An  ordinary  test  of 
purity  is  a  mixture  with  equal  parts  of  pure  sulphuric  acid,  which  should  produce 
no  discoloration.  The  impure  article  colors  the  acid  brown.  It  is  not  inflammable, 
and  on  t^iis  account  it  may,  in  certain  cases,  be  preferred  to  ether. 

The  preparations  for  chloroform  narcosis  differ  in  no  essential  feature  from 
those  given  for  ether.  A  much  smaller  quantity  is  necessary,  and,  in  general,  it  is 
a  wise  precaution,  except  in  the  very  young  and  very  old,  to  give  a  hypodermic 
of  morphia  (gr.  |)  with  atropia  (gr.  yfj-)  twenty  minutes  before  the  antesthesia. 


AN^STHESLA.  23 

The  open  icarm  vapor  method  with  the  Gwathmey  apparatus  (Fig.  30)  regulates 
the  quantity  administered,  and  brings  it  in  contact  with  the  respiratory  surfaces 
at  nearly  the  normal  temperature.  It  also  permits  the  induction  of  ox\-gen  as 
required  or  the  change  to  ether. 

Xext  in  order  of  preference  is  the  Esmarch  screen  (Fig.  37),  but  a  napkin  or 
gauze  mat  will  suffice.     Chloroform  shoidd  be  warmed  by  placing  the  bottle  every 


Fig.  37. — Esmarch's  chloroform  screen. 


minute  or  two  in  a  basin  of  hot  water.  It  is  believed  to  possess  less  danger  when 
heated,  and  to  be  safer  in  warm  weather  or  in  a  warm  climate  than  in.  regions  of 
low  temperature. 

The  administration  is  begun  by  pouring  five  or  ten  drops  upon  the  inhaler, 
permitting  a  free  admixture  of  air.  It  is  advisable  to  smear  the  skin  about  the 
mouth  and  nose  with  vaseline,  to  prevent  irritation.  The  auEesthetic  is  added  drop 
by  drop  until  consciousness  is  lost.  At  no  one  time  should  more  than  a  few  drops  be 
added.  In  the  first,  or  stage  of  excitation,  the  pidse  is  increased  in  force  and 
frequency,  the  face  flushed,  the  pupil  normal  or  at  times  contracted.  Delirium 
ma}-  be  present,  with  muscular  rigidity  varying  in  degree  with  different  subjects. 
It  is  almost  always  well  marked  in  patients  of  the  alcohol  habit.  As  given  on  a 
preceding  page,  ether  should  be  substituted  with  threatened  heart  failure  or 
asphvxia.  The  second  stage  is  that  in  which  sensibDity  and  consciousness  are  lost, 
the  functions  of  the  heart  and  respiratory  organs  being  performed  in  an  almost 
natural  manner.  The  pupil  is  slightly  dilated,  and  arterial  tension  diminished. 
In  the  th  ird  stage,  that  of  profound  relaxation,  the  breathing  becomes  more  shal- 
low, and  at  times  stertorptis';  the  heart  beats  rapid  and  weak,  and  arterial  tension 
is  markedly  diminished. 

The  second  is  the  operative  stage,  the  third  should  be  avoided.  It  is  more  im- 
portant to  administer  a  preliminary  injection  of  morphia  and  atropia  in  chloroform 
than  in  ether  narcosis.  Death  during  the  inhalation  of  chloroform  occurs  more 
frequently  from  heart  failure,  although  respiratory  paralysis  may  ensue.  Death 
from  chloroform  due  to  heart  failure  is  very  sudden.  There  are  no  premonitorj- 
symptoms,  and  restoration  of  function  is  almost  always  hopeless.  When  this  acci- 
dent occurs  the  heart  should  be  massaged  as  just  described. 

yitrous  oxide  is  not  only  safe,^  but  simple  in  administration,  producing  in  one 
or  two  minutes  complete  insensibilitv.  In  expert  hands,  with  the  admixture  of 
air  or  oxygen,  as  may  be  indicated,  an  anaesthesia  lasting  two  hours  or  longer 
may  be  satisfactorily  maintained. 

Xitrous  oxide  of  the  purest  qualitv-,  condensed  in  portable  cylinders  containing 
a  sufficient  quantity  for  twenty  ordinary  administrations,  can  be  obtained  from 
reliable  manufacturers. 

When  gas  alone  is  to  be  administered,  the  tube  at  the  end  of  the  balloon  is 

'  One  operator  in  New  York  City  has  employed  it  in  more  than  100,000  instances  without  an 
accident. 


24 


ANAESTHESIA 


connected  with  the  tube  leading  from  the  cylinder,  the  cylinder  cock  is  opened, 
and  a  sufBeient  quantity  of  gas  allowed  to  flow  in  until  the  balloon  is  aboiit  three 
fourths  distended.  The  face  piece  is  now  closely  applied  over  the  mouth  and  nose, 
so  that  no  air  can  be  admitted,  and  the  patient  is  told  to  breathe  deeply  and  some- 
what more  rapidly  than  normal.  In  from  thirty  to  sixty  seconds  the  color  of  the 
skin  changes  to  a  dark  red,  at  times  almost  purple  hue;  there  is  usually  muscular 
tremor  or  momentary  rigidity,  with  incoherent  speech,  but  in  a  very  short  time 
these  symptoms  pass,  with  complete  insensibility  to  pain.     If  the  lifted  arm  falls 


!FlG.   38. — Portable  combination  heated  nitrous  oxide  and  oxygen  apparatus. 


to  the  patient's  side,  the  .surgeon  can  proceed  with  the  operation.  By  allowing 
the  patient  to  take  two  inspirations  of  the  gas  and  one  of  free  air  (fourteen  to 
eighteen  per  cent  for  men  and  eighteen  to  twenty-two  per  cent  for  women),  the 
narcosis  may  l^e  safely  continued  for  an  hour  or  more.  When  given  alone,  or  in 
combination  with  ether,  it  is  advisable  to  employ  the  thermal  mechanism  devised 
by  Dr.  Ernest  Brown  (Fig.  38),  in  which  apparatus  the  gas  passes  through  a  coil 
of  pipe  in  contact  with  hot  water. 

In  addition  to  its  usefulness  alone  in  the  long  list  of  operations  above  given, 
it  is  invaluable  when  comlnned  with  ether  for  prolonged  anesthesia.  The  patient 
within  a  minute  or  two  becomes  unconscious  from  the  gas,  and  does  not  feel  the 


AN^STHESLV  25 

irritation  of  the  larynx  nor  the  sense  of  strangulation  and  anxiety  which  ether 
alone  produces. 

For  its  administration  a  close-fitting  mouth-and-nose  piece  is  essential,  to  which 
is  attached  a  rubber  balloon.  This  combined  ether  and  nitrous  oxide  inhaler  (Fig. 
29)  is  so  arranged  that  the  patient,  for  the  first  minute  or  two.  tohales  only  gas, 
and  when  rendered  iusensible  by  this  agent  the  ether  is  turned  on  very  gradually, 
so  as  not  to  irritate  the  larynx.  The  quantity"  of  gas  is  then  gradually  diminished 
mitil,  within  from  three  to  five  minutes  from  the  commencement  of  the  admui- 
istration,  ether  alone  is  given  and  the  gas  reservoir  entirely  disconnected. 

In  expert  hands  this  method  is  so  satisfactory  that  patients  become  fully  un- 
conscious and  relaxed  without  a  struggle,  and  with  the  use  of  the  smallest  possible 
quantity"  of  ether. 

\Yhen  a  combination  gas  and  ether  inlialation  apparatus  is  not  at  hand,  a  com- 
promise can  be  made  by  emplojing  any  open  uihaler,  such  as  the  Allis,  around 
one  end  of  which  an  ice-bag  or  oil  silk  has  been  tied.  The  nitrous  oxide  can  be 
administered  at  first  through  the  gas  inhaler,  and  as  soon  as  the  patient  is  uncon- 
scious the  modified  ether  apparatus  applied. 

Nitrous  Oxide  and  Oxygen. — The  proper  admixture  of  nitrous  oxide  and  oxygen 
produces  a  most  satisfactory  amesthesia.  The  combined  apparatus  is  shown  in 
Fig.  38.  It  is  so  arranged  that  by  turning  a  key  any  desired  admixture  of  the 
two  gases  may  be  obtained.  The  usual  proportion  of  oxygen  is  from  five  to  eight 
per  cent. 

The  nitrous  oxide  escaping  from  the  cylinders  passes  through  a  metal  coU 
submerged  in  hot  water,  which  warms  the  gas  to  the  proper  degree.  So  cold  is 
this  vapor  under  pressure  that  the  lower  portions  of  the  cylinders  are  frequently 
entirely  congealed.  The  author  has  used  this  method  in  a  very  considerable  number 
of  cases  (gallstone,  varicose  veins,  etc.),  and  has  found  it  satisfactory  in  every 
respect. 

The  narcosis  is  induced  without  excitement  or  any  disagreeable  sensation,  the 
color  of  the  skin  is  normal,  and  the  ordinary  suggestions  of  asphyxia  so  common 
to  other  aniestheties  are  absent.  The  pulse  is  usually  accelerated,  being  about  80 
to  90  beats  per  minute.  In  no  instance  has  it  been  followed  by  vomiting  or  any 
symptoms  of  inertia  in  the  alimentary  canal.  It  carries  with  it  no  danger  to  the 
kidneys,  the  respiratory  apparatus,  or  tlie  heart,  and  when  its  value  is  fully 
appreciated  it  wiU  supplant  in  large  measure  the  administration  of  ether  or 
chloroform.  < 

In  patients  of  high  tension  it  is  advised  to  administer  a  preliminary  injection 
of  ^  to  ^  of  a  grain  of  morphia  thirty  minutes  before  the  anaesthesia  is  commenced. 
This  should  not  be  done  as  routine  practice,  but  only  in  exceptional  cases.  It  is, 
in  general,  better  not  to  use  morphia  before  or  after  a  surgical  operation,  on  account 
of  its  tendency  to  produce  intestinal  paralysis  and  to  interfere  with  the  normal 
secretory  apparatus. 

If,  in  the  coui-se  of  an  operation,  by  reason  of  extreme  muscular  resistance  (as 
in  laparotomy),  a  more  complete  relaxation  is  required,  the  addition  of  a  small 
quantity-  of  ether  (.3SS-.dJ)  will  produce  the  necessary  relaxation  and  a  sufficiently 
profound  narcosis.  In  no  instance  has  the  author  used  in  any  operation  more  than 
5jv  of  ether,  and  in  the  large  majority  of  instances  in  which  it  was  combined 
with  nitrous  oxide  and  oxygen  the  quantitv  was  not  over  oij. 

One  of  the  chief  values  of  this  narcosis  is  that  none  of  the  distressing  after- 
effects of  ether  or  chloroform  upon  the  heart,  Itmgs,  or  kidneys  are  present,  and 
vomiting  is  absent.  The  apparatus  is  so  arranged  that  the  ether  can  be  poured 
into  the  chamber  of  communication  between  the  oxA-gen  and  nitrous  oxide  cylinders, 
and  can  be  turned  on  or  off  as  required. 

Cocaine.^ — Applied  to  the  cornea  and  conjunctiva  by  dropping  one  or  two  minims 
of  a  two-per-cent  solution  into  the  eye  or  upon  any  mucous  surface,  within  a  few 
moments  it  completely  deadens  local  sensibility.     Upon  the  unbroken  integument 

'  The  human  race  will  ever  be  iadebted  to  Dr.  Carl  KoUer,  of  New  York,  who  discovered 
the  aiiEesthetic  properties  of  this  agent  when  applied  to  the  eye  and  mucous  surfaces,  and  to 
Dr.  J.  Leonard  Coming,  of  Xew  York,  who  first  demonstrated  its  use  by  hypodermic  injection. 


26  ANAESTHESIA 

it  has  no  effect.  Injected  into  the  tissues  through  a  hy|oodermic  needle,  it  pro- 
duces aneesthesia  within  the  range  of  contact.  In  the  suljstance  of  a  nerve  it  is 
rapidly  absorbed,  and  within  a  few  minutes  produces  complete  aneesthesia  in  all 
parts  in  the  range  of  distribution  of  the  nerve  trunk  beyond  the  point  of  injection. 
So  emplo3'ed,  it  lessens,  and  may  prevent,  shock  from  the  traumatism  of  an  opera- 
tion by  paralyzing  nerve  conductivity  and  preventing  the  registration  by  the  brain 
cells  of  the  sense  of  injury  in  the  field  of  operations.  For  this  reason  Crile  advises 
its  employment  as  a  preliminary  to  amputations  or  other  major  operations  upon 
the  extremities,  even  when  general  narcosis  is  to  be  employed. 

The  qriantity  to  be  used  will  vary  with  the  susceptibility  of  the  individual  and 
the  extent  of  the  dissection.  By  the  infiltration  method  with  the  weaker  solutions, 
introduced  by  Schleich,  and  more  thoroughly  developed  by  J.  A.  Bodine  in  the 
operation  for  the  radical  cure  of  hernia,  etc.,  all  danger  from  cocaine  poisoning  is 
practically  removed.  The  solutions  should  be  sterile,  and  should  be  prepared  im- 
mediately before  injection,  for  the  reason  that  they  rapidly  develop  a  fungus.  It 
is,  moreover,  not  safe  to  employ  a  cocaine  solution  which  has  been  boiled.  In- an 
emergencj'  a  fairly  sterile  product  may  be  secured  by  dissolving  clean  crystals  in 
normal  salt  solution  heated  for  a  few  minutes  just  short  of  the  boiling  point  (about 
190°  ¥.). 

Bodine  uses  a  preparation  of  sterile  cr3rstalline  cocaine,  plus  sufficient  sodium 
cHoride,  enclosed  in  a  sealed  tube ;  ^  the  quantity  in  each,  when  dissolved  in  an 
ounce  of  water  that  has  just  been  boiled  and  allowed  to  cool  to  about  the  body 
temperature,  makes  a  1-500  cocaine  normal  salt  solution.  This  stock  solution  is 
used  to  anesthetize  the  skin  in  the  line  of  incision  (endermie),  and  nerve  trunl-s 
when  encountered,  but  for  subdermic  infiltration  a  1-1000  solution  is  employed. 

The  Kny-Scheerer  Co.,  N.  Y. 


?|1lTrltl1lTtlTriTi'  1 1 1 1 1 11 1  an 


Fig.  39. — Glass  sj'ringe  for  infiltration. 

This  is  secured  by  partially  filling  the  glass  syringe  with  the  1-500,  and  then 
drawing  into  the  barrel  an  equal  quantity  of  sterile  salt  water.  Any  hypoder- 
mic syringe  and  needle,  if  properly  sterilized,  may  be  employed,  although  the 
simple  glass  instrument  (Fig.  39)  is  preferable.  Two  or  three  of  these  (hold- 
ing oj  or  oij)  should  be  kept  at  hand  so  that  the  infiltration  may  be  rapidly 
accomplished. 

Since,  in  operations  under  cocaine  anesthesia,  the  patient  is  entirely  conscious, 
and  naturally  more  or  less  apprehensive,  it  is  exceedingly  important  that  the 
operator  should  take  every  possible  precaution  to  allay  anxiety  and  to  prevent 
panic.  He  should  carefully  note  the  peculiarities  of  the  individual,  and  deport 
himself  accordingly.  By  speech  and  manner  he  should  convey  the  impression  to 
the  mind  of  the  subject  that  the  operation  is  not  only  entirely  free  from  danger, 
but  painless  withal.  This  statement  may  be,  in  a  measure,  qualified  by  the  sugges- 
tion that  in  case  there  should  be  the  least  sensation  of  pain,  the  attention  of  the 
operator  be  called  to  it  by  word,  and  not  by  movement. 

With  the  majorit}'  of  patients  it  is  advisable  to  keep  instruments  and  apparatus 
concealed,  and  under  no  circumstances  to  permit  the  patient  to  view  the  operative 
wound.  When  an  instrument  is  desired,  the  operator  should  pick  it  up,  or  indicate 
it  without  speaking.  The  call  for  a  knife  or  scissors,  as  well  as  the  sight  of  blood, 
may  unnecessarily  excite  apprehension.  Although  no  pain  is  experienced,  the  click 
of  the  scissors  may  compel  the  operator  to  dissect  with  the  knife. 

'  Parke,  Davis  &  Co, 


ANESTHESIA  27 

Individuals  who  are  naturally  nervous  and  overexcitable,  and  children  who  are 
unable  to  control  themselves^  are  not  suitable  subjects  for  cocaine  surgery. 

In  all  instances  where  a  prolonged  operation  is  undertaken  under  cocaine  anses- 
thesia,  a  hypodermic  of  ^  of  a  grain  of  morphia  is  advised  five  or  ten  minutes  before 
the  infiltration  is  given.  Morphia  is  not  only  an  antidote  to  cocaine  poisoning, 
but  tends  to  allay  anxiety. 

For  the  first  injection  into  the  skin  a  very  delicate  needle  should  be  used.  This 
should  be  shown  to  the  patient,  with  the  statement  that  there  will  be  no  pain  beyond 
the  initial  prick  of  the  needle,  for  it  is  very  important,  in  order  to  retain  the  con- 
fidence of  the  subject  throughout  the  operation,  to  minimize  even  the  small  pain 
of  the  initial  puncture.  In  a  timid  and  overexcitable  subject,  so  important  is  it 
that  implicit  confidence  be  won  at  the  very  threshold  of  the  operation,  it  is  a  wise 
precaution  to  deaden  sensation  of  the  initial  morphia  and  cocaine  punctures  by 
applying  a  spray  of  ether  from  the  Eichardson  atomizer,  or  by  holding  a  piece  of  ' 
ice  to  the  skin  for  a  few  minutes.  The  hypodermic  needle  should  be  entered  almost 
parallel  with  the  surface  of  the  skin  to  be  anaesthetized,  the  point  and  shaft  being 
scarcely  hcncatli.  the  epidermis,  for  here  the  end  organs  of  the  sensory  nerves  are 
most  successfully  paralyzed  with  the  minimum  of  sohition.  When  pressure  is  made 
upon  the  piston  and  three  or  four  minims  have  been  forced  out,  the  skin  is  slightly 
distended,  becomes  pale,  and  is  anajsthetized.  It  should  then  be  further  introduced 
to  its  full  length,  and  more  solution  injected.  It  should  now  be  withdrawn,  a 
larger  needle  quickly  substituted,  and  inserted  through  the  edge  of  the  anaesthetized 
area,  and  in  the  track  of  the  ]iroposed  incision.  This  should  be  repeated  ad  finem. 
The  underlying  fat  in  the  field  of  operation  should  then  be  thoroughly  infiltrated 
with  the  weaker  1-1000  solution  heforc  the  shin  is  incised. 

Should  a  sensitive  area  be  encountered,  as  when  a  blood  vessel  or  nerve  trunk 
comes  in  the  line  of  dissection,  one  or  two  minims  of  the  stock  solution  should 
be  injected  into  or  immediately  about  the  nerve. 

When  operating  wpon  the  extremities  it  may,  in  certain  conditions,  be  advisable 
to  produce  blood  stasis  by  the  use  of  the  rubber  tournicfuet.  When  this  is  done, 
the  cocaine  solution  remains  for  the  time  being  stagnant,  and  in  actual  contact 
with  the  sensory  end  organs.  When  the  operation  is  finished,  and  when  a  consid- 
erable quantity  has  been  used,  it  is  a  wise  precaution  not  to  remove  the  tourniquet 
and  allow  all  the  solution  to  be  carried  too  rapidly  and  in  too  large  volume  into 
the  general  circulation.  This  can  be  avoided  by  loosening  the  tourniquet  for  about 
ten  seconds,  tiglitening  it  again  for  a  minute,  and  repeating  this  through. five  or 
ten  minutes,  thus  giving  an  opportunity  for  the  gradual  distribution  and  elimina- 
tion of  the  cocaine. 

Cocaine  infiltration,  either  free  or  in  stasis,  when  properly  done,  does  not  inter- 
fere with  the  process  of  repair  in  the  field  of  operation. 

Any  variation  from  the  technic  above  described  will  be  given  in  connection  with 
the  operations  in  which  the  change  may  be  deemed  advisable. 

As  heretofore  stated,  with  these  cocaine  solutions  properly  employed,  operations 
of  the  magnitude  of  thyroidectomy  may  be  satisfactorily  done.  The  Kochers  of 
Berne  have  performed  nearly  two  thousand  thyroidectomies  with  no  other  anses- 
thetization  than  cocaine  infiltration.  All  operations  upon  bone  can  be  done  with 
perfect  insensibility  after  cocaine  anassthesia,  provided  the  periosteum  is  thoroughly 
infiltrated.  All  the  abdominal  viscera  are  entirely  insensible  to  pain,  and  unless 
the  mesentery  be  dragged  upon,  all  explorations  and  extensive  operations  may  be 
done  with  cocaine  antesthesia.  provided  the  peritonseum  of  the  abdominal  wall, 
which  is  exquisitely  sensitive,  be  thoroughly  anaesthetized. 

Qiiinia  and  Urea  Hydrochloride  has  been  demonstrated  by  Dr.  H.  Thibault,  of 
Arkansas,  to  be  a  local  anaesthetic  of  great  value.  Injected  into  and  beneath  the 
skin  in  the  same  way  as  advised  for  cocaine  infiltration  (a  two-per-cent  solution  for 
the  endermic  and  one-per-cent  for  the  hypodermic  injection),  it  rapidly  produces 
analgesia,  the  anaesthetic  effect  lasting  longer  than  that  of  cocaine.  Ten  grains 
dissolved  in  one  ounce  of  normal  salt  is  approximately  a  two-per-cent  solution.  It 
may  be  rendered  entirely  sterile  by  boiling  just  before  using,  and  so  far,  in  the 
large  number  of  cases  in  which  it  has  been  successfully  employed,  no  constitutional 


28  ANAESTHESIA 

symptoms  have  been  observed.^  A  fifteen-pcr-cent  solution  applied  on  pledgets 
of  cotton  to  an  ulcerated  surface  will  render  curetting  painless  (Thibault).-  A 
ten-  to  fifteen-per-cent  solution  applied  to  the  mucous  surfaces  will  also  produce 
analgesia. 

Rectal  Anwsthesia. — Ether  vapor,  absorbed  by  the  mucous  membrane  of  the 
colon,  will  produce  narcosis.  A  number  of  fatal  cases  have  been  reported,  and  it 
is  now  rarely  employed.  Carefully  administered  in  properly  selected  cases,  it  has 
its  place  in  surgery. 

The  warmed  vapor  is  carried  into  the  bowel  through  a  soft  rubl^er  tulje,  one 
end  of  which  is  introduced  into  the  rectum  as  high  as  the  sigmoid  colon,  the  other 
being  connected  with  the  vessel  holding  the  ether.  This  is  placed  in  warm  water, 
about  100°  F.,  at  which  temperature  it  is  rapidly  vaporized.  A  very  small  quantity 
of  vapor  should  be  allowed  gradually  to  enter  the  bowel,  and  shoiild  overintoxication 
occur,  a  second  tube  of  larger  caliber  should  be  introduced  to  permit  the  excess 
of  gas  and  vapor  to  escape. 

This  method  was  formerly  recommended  in  operations  aljout  the  mouth  and 
upper  air  passages,  since  it  did  away  with  the  inlialing  apparatus  and  allowed  un- 
interrupted access  to  the  operative  field,  but  since  the  introduction  of  Dawbarn's 
sequestration  method,  after  the  narcosis  is  complete,  the  quantity  of  the  ansesthetic 
necessary  is  so  insignificant  that  operations  in  this  region  can  be  done  without 
interference. 

Spinal  Analgesia. — It  has  been  demonstrated  that  a  sterile  cocaine  solution, 
injected  into  the  cavity  of  the  arachnoid,  will  produce  a  general  analgesia.  Its 
administration  is  considered  somewhat  more  hazardous  than  chloroform  or  ether 
narcosis,  or  local  cocaine  infiltration,  and  for  this  reason  the  method  has  not  been 
more  widely  adopted.  Under  certain  conditions,  where  ether  or  chloroform  may 
not  be  tolerated,  and  where  infiltration  will  not  suffice,  it  may  be  properly  and 
satisfactorily  employed. 

It  requires  from  10  to  25  minims  of  a  two-per-cent  solution  to  produce  a  satis- 
factory anaesthesia,  and  in  some  instances  this  may  have  to  be  repeated.  In  chil- 
dren from  twelve  to  sixteen  years  of  age,  from  10  to  15  minims  will  suffice;  in 
older  persons,  20  to  25  minims  (W.  S.  Bainbridge). 

The  patient  is  seated  upon  the  operating  table,  leaning  forward  so  as  to  sepa- 
rate as  widely  as  possible  the  laminse  of  the  lumbar  vertebra?,  or  resting  upon  the 
side,  this  position  may  be  assumed.  The  point  of  election  is  between  the  laminae 
of  the  first  and  second  or  second  and  third  lumbar  vertebrae,  and  careful  asepsis 
is  imperative. 

Superficial  infiltration  may  be  employed  to  prevent  pain.  Through  a  skin  punc- 
ture with  a  bistoury  a  needle  three  or  four  inches  long  is  carried  obliquely  from 
below  upwards,  until  it  strikes  the  lamina  on  one  or  the  other  side  of  the  spine; 
it  is  then  slightly  tilted  and  carefully  guided  through  the  space  between  the 
laminffi,  and  is  slowly  pushed  through  the  dura  into  the  cavity  of  the  arachnoid. 
The  entrance  of  the  needle  point  into  this  cavity  is  indicated  by  the  escape  of  a 
few  drops  of  clear  fluid.  Witliout  moving  the  needle  point,  the  syringe  is  now 
attached  to  it,  and  the  cocaine  forced  gently  in.  The  quantity  of  solution  injected 
should  about  equal  that  of  cephalo-rachidian  fluid  wliich  is  j)ermitted  to  escape. 

_'  It  occurs  as  colorless  crystals  or  as  a  white  powder  that  is  sohible  in  about  an  equal  part  of 
distilled  water  and  also  freely  soluble  in  alcohol.  It  contains  seventy  per  cent  of  alkaloidal 
quinia  and  about  seventeen  per  cent  of  urea  hydrochloride.  The  ordinary  dose  subcutaneously 
as  an  antiperiodic  is  5  to  15  grains,  injected  in  concentrated  (about  fifty  per  cent)  solution;  but 
doubtless  considerably  greater  quantities  can  be  used  hypodermically.  Urea  pure  is  used  as  a 
diuretic  per  os  in  doses  of  1 0  to  20  grains  three  or  four  times  daily.  The  urea  in  the  quinia  double 
salt  is  considered  to  be  void  of  toxic  action.     (E.  R.  Squibb  &  Sons.) 

2  Dr.  Thibault  reports  sixty-five  minor  operations  in  which  the  anaesthesia  was  perfect,  and 
in  various  procedures  in  which  it  has  been  employed  at  the  New  York  Polyclinic  Medical  School 
and  Hospital,  the  results  have  been  very  satisfactory. 


CHAPTER    III 


BANDAGING 


Bandages  are  emplo_yed  in  surgical  practice  to  retain  dressings  in  piosition,  to 
secure  compression  and  suppoi-t  to  any  portion  of  the  body,  to  maintain  any  required 
degree  of  immobility,  and  to  render  an  extremity  partially  or  completely  bloodless. 

They  are  made  of  cotton  muslin  of  various  degrees  of  fineness,  crinoline,  woolen 
goods,  and  India  rubl3er.  Cotton  bandages  are  most  generally  employed,  but,  on 
account  of  the  greater  elasticity  of  flannel,  these  are  preferable  for  certain  special 
dressings.  Crinoline  is  used  chiefly  for  plaster-of-Paris  bandages.  Martin's  rubber 
bandage  and  Esmarch's  bloodless  tourniquet  are  very  useful  in  maintaining  the 
firm  compression  of  a  part,  either  as  a  means  of  support  or  of  emptying  the 
vessels. 

The  muslin  should  be  soft,  not  starched,  and  of  two  kinds — a  fairly  heavy 
qualit}',  and  the  light  cheese-cloth.  Both  should  be  cut  in  pieces  from  eight  to 
ten  yards  in  length.  The  former  can  be  torn;  the  latter  must  be  cut.  The  selvage 
edge  is  removed,  and  the  cloth  divided  into  strips  varying  in  width  from  four, 
three,  two  and  a  half,  and  two  inches,  with  some  one  inch  or  less  in  width.  For 
the  chest  and  abdomen  the  wide  bandages  are  needed,  the  two-  and  three-inch 
strips  for  the  arms,  legs,  head,  and  neck,  and  the  narrow  strips  for  the  hands 
and  fingers.  All  the  loose  ravelings  along  the  edges  should  be  pulled  off,  and 
the  liandages  made  into  compact,  smooth  rollers. 

Bandages  may  be  rolled  by  hand,  but  the  work  can  be  better  and  more  rapidly 
done  by  machinery.  In  Fig.  40  is  pictured  a  bandage  roller,  simple  in  construction 
and  cheap.  It  should  be  fastened  to  the  edge  of  a  solid  table  by  screws  or  movable 
clamps.  The  end  of  the  strip  to  be  wound  is  passed  in  and  out  over  the  four  bars 
at  the  base  and  apex  of  the  machine,  and 
then  around  the  shaft,  so  that  one  edge  of 
the  bandage  touches  the  end  of  the  up- 
right. As  the  crank  is  turned,  the  strip 
is  held  tightly,  and,  as  it  runs  over  the 
rods,  wrinkling  or  folding  is  prevented.  A 
home-made  apparatus  may  be  constructed 
as  follows :  Take  a  cigar-box,  remove  the 
top  and  one  end,  bore  a  hole  in  each  side- 
piece  near  the  open  end,  and  through  the-.e 
pass  a  piece  of  telegraph  wire  bent  in  the 
shape  of  a  windlass  and  crank.  Wires  may  be  run  through  at  other  points  to  serve 
the  same  purpose  as  the  four  rods  in  the  other  machine,  or  a  chink  cut  in  the  end 
through  which  the  bandage  travels  toward  the  spindle. 

In  making  plaster-of-Paris  bandages,  these  same  machines  may  be  employed, 
but  the  crinoline  must  be  loosely  rolled,  and  the  powdered  plaster  worked  in  with 
the  hands  so  well  and  thoroughly  that  the  meshes  of  the  cloth  cannot  be  seen. 
Considerable  experience  is  required  to  prepare  a  good  plaster  bandage,  and  a  poor 
one  will  spoil  a  dressing.  Plaster  bandages  shoidd  be  made  from  fresh  gypsum  on 
the  day  they  are  to  be  aiiplied.  Cotton  and  flannel  bandages  should  be  kept  in  a 
chest  or  closet  away  from  dust  and  moisture.  Plaster  or  plaster  bandages  which 
have  deteriorated  from  absorption  of  moisture  should  be  subjected  to  dry  heat  in 
an  oven  to  drive  out  the  excess  of  moisture.     These  bandages  are  now  prepared 

29 


Bandage 


30 


BANDAGING 


and  kept  in  hermetically  sealed  cans,  in  which  they  are  preserved  indefinitely.  They 
are  of  inestimable  value  in  the  treatment  of  fractures. 

Methods  of  Applying  Bandages. — The  various  portions  of  the  body  may  be 
bandaged  by  the  simple  spiral^  reverse  spiral,  simple  figure-of-S,  and  the  figure-of-8 
reverse.  . 

The  simple  spiral  turn  is  most  useful  in  bandaging  those  parts  of  the  body 
where  there  is  no  sudden  increase  in  the  diameter  and  volume  of  the  part.  It  is 
impracticable  under  other  circumstances. 

Hold  the  bandage  in  the  hand  most  convenient,  with  the  back  of  the  roller 
toward  the  limb  (see  Fig.  41) ;  with  the  imoceupied  hand  take  the  free  end  of 
the  bandage,  lay  and  hold  it  upon  the  inner  border  of  the  limb,  and  carry  the 

turn  by  the  front  to  the  outer  side  of 
the  2)art  to  he  bandaged. 


Fig.  41. — Simple  spiral  bandage. 


FiG:  42. — Reverse  bandage. 


Having  carried  the  roller  twice  around  the  part  to  secure  it,  ascend  the  limb 
spirally,  leaving  about  one  third  of  each  turn  uncovered  by  the  last. 

The  reverse-spiral  turn   (Fig.  42)   is  applied  as  follows: 

Taking  the  left  arm  to  be  bandaged,  hold  the  roller  in  the  right  hand,  with  its 
convexity  toward  the  limb,  and  carry  it  from  the  inner  or  ulnar  border,  by  the 
front,  to  the  outer  or  radial  border,  and  thus  around  the  arm  by  two  circular  turns 
to  secure  the  roller.  Then,  having  carried  the  bandage  to  the  outer  side,  ascending 
the  limb  gradually,  lay  the  thumb  of  the  left  hand  upion  the  lower  edge  of  the 
bandage,  press  it  firmly  against  the  limb  to  prevent  slipping,  loosen  the  roller 
considerably  in  the  right  hand,  at  the  same  time  turning  it  one-half  turn  toward 
the  operator.  This  process  is  to  be  repeated  as  often  as  necessary,  keeping  the 
.reverses  well  upon  the  outer  border  and  anterior  aspect  of  the  extremity. 

The  Simple  Figure-of-S  Turn. — After  the  bandage  is  secured,  as  heretofore 
described,  ascend  the  limb  sharply,  from  the  inner  to  the  outer  border,  so  that 
at  this  outer  border  the  lower  edge  of  the  roller  shall  be  se^•eral  inches  above 
the  starting-point.  Carry  the  roller  dircctlv  across  and  iehind  the  limb  to 
the  same  point  on  the  opposite  side;  then  oljliquely  do^vnward  in  front,  cross- 
ing the  ascending  turn  at  a  riglit  angle.  When  the  outer  border  is  again 
reached,  carry  the  roller  behind  and  directly  across  the  limb  to  the  starting-point 
(see  Fig.  43). 


BANDAGING 


31 


The  Figitre-of-S  Eeverse. — Commence  exactl}'  as  for  the  simple  figure-of-8  until 
the  bandage  has  passed  across  the  posterior  aspect  of  the  limb,  and  is  about  to 
descend  obliquely  along  the  inner  aspect  to  the  front.  With  the  index-finger  of 
the  unoccupied  hand  hold  the  lower  edge  of  the  bandage  tightly  against  the  part, 
while  the  roller  is  slackened  and  turned  half  over  in  a  direction  away  from  the 
limb.  This  reverse  in  the  figure-of-S  may  also  be  made  anteriorly,  and,  when 
the  conformation  of  the  part  demands  it,  may  be  made  both  anteriorlj'  and  pos- 
teriorly. 

Of  these  four  methods,  the  simple  spiral  is  more  readily  applied.  When  the 
diameter  of  the  extremitj''  increases  rapidly  it  will  not  suffice,  since  it  grasps  the 
part  at  the  upper  edge  of  the  roller  while  the  lower  stands  out  free  and  loose. 

For  all  purposes  the  spiral  reverse  is  more  generally  useful.  In  competent 
hands  it  can  be  applied  to  all  portions  of  the  body  except  where  the  members  join 
the  trunk,  when  it  must  give  place  to  the  simple  figure-of-S  turn.  Thus,  the  spica 
at  the  groin  and  shoulder,  the  occiput  and  chin  dressings,  and  the  neck  and  shoul- 
der bandages,  must  describe  this  shape.  The  figure-of-8  reverse  is  of  great  iise 
in  getting  over  the  calf  of  the  leg  in  ver}'  muscular  subjects,  where  not  infrequentlj' 
all  the  other  methods  will  fail  to  hold. 

The  important  rule  in  bandaging  is  to  equalize  the  jxressure  from  periphery 
to  center.    The  circumstances  of  the  case  will  determine  the  degree  of  compression. 


Fig.  43.— The  figure-of-8  method. 


Fig.  44. — Hand-,  thumb-,  and  finger-bandage. 
(The  author's  modification  of  the  old  method.) 


It  requires  a  great  deal  of  study  and  practice  to  become  expert  in  appljdng  dress- 
ings. One  should  thoroughly  familiarize  one's  self  with  each  of  the  methods,  for 
not  infrequently  a  part  to  be  dressed  will  require  a  combination  of  several  methods. 
The  question  of  how  tight  to  apply  the  bandage  may  in  part  be  left  to  the  sense 
of  the  patient  when  an  anesthetic  is  not  employed.  After  an  extensive  operation, 
in  which  Esmarch's  bandage  has  been  applied,  a  very  considerable  degree  of  com- 
pression is  often  required  to  prevent  the  oozing  which  otherwise  would  follow  the 
use  of  this  tourniquet.  Xo  amount  of  description  will  impart  this  sense  to  the 
inquirer ;  it  can  only  come  from  personal  experience.  One  precaution  is  imijerative : 
the  tips  of  the  fingers  or  toes  of  the  extremity  bandaged  must  always  be  left  open 


32  BANDAGING 

for  observation,  for  if  strangulation  is  threatened  it  will  always  be  earliest  indi- 
cated here.  A  watch  should  be  set  on  eveiy  case  where  there  is  ground  for  anxiety, 
with  directions  to  slit  the  dressing  with  the  appearance  of  any  symptom  of  strangu- 
lation. 

Special  Bandages — The  Hand  and  Fingers  lij  tlie  First  Method  (Fig.  H). — 
Take  a  roller  between  three  fourths  and  one  inch  in  width,  and  ten  yards  in  length. 
Let  the  hand  to  be  bandaged  be  pronated,  and  commence  by  taking  two  or  three 
turns  of  the  roller  around  the  carpus,  going  from  the  radial  over  the  back  of  the 
wrist  to  the  ulnar  side.  Having  in  this  manner  secured  the  roller,  carry  it  from 
the  radial  side  of  the  wrist  obliquely  across  the  dorsum  of  the  hand  to  the  ulnar 
border  of  the  root  of  the  little  finger,  then  spirally  around  the  little  finger  two  turns 
to  its  extremity.  Next,  return  by  careful  spiral  turns,  or  a  spiral  reverse,  if  neces- 
sary, to  the  root  of  the  finger,  covering  it  equally  and  nicely.  From  the  radial 
border  of  the  base  of  the  finger  the  bandage  is  carried  over  the  back  of  the  hand 
to  the  ulnar  side  of  the  carpus,  then  under  the  wrist,  by  the  front,  to  the  radial 
side,  and  again  over  the  dorsum  of  the  hand  around  to  the  ulnar  side  of  the  same 
finger,  repeating  the  figure-of-8,  as  before.  Two  turns  are  then  thrown  around 
the  wrist  to  secure  the  former  bandage,  and  the  roller  is  carried  in  the  same  manner 
to  the  remaining  fingers. 

When  the  index-finger  is  reached,  on  account  of  the  great  space  between  its 
root  and  the  thumb,  it  is  advisable  to  make  four  or  five  extra  figure-of-8  turns 
around  its  base,  carrying  the  bandage  a  little  lower  with  each  successive  layer  toward 
the  thumb. 

Having  reached  the  thumb,  the  roller  is  carried  spirally  to  its  extremity,  as  in 
the  other  fingers,  but  in  returning,  when  the  last,  the  interphalangeal,  joint  is 
reached,  the  figure-of-8  turn  is  commenced  at  this  point,  and  continued  until  the 
ball  of  the  thumb  is  completely  covered. 

This  method  may  be  applied  to  the  thumb  alone,  or  to  any  one  or  more  of  the 
fingers,  when  the  remainder  of  the  hand  does  not  need  to  he  bandaged,  and  is 
equally  efficient  in  securing  splints  to  these  organs. 

One  objection  to  it,  and  a  very  formidable  one  to  the  practitioner,  is  the  length 
of  time  necessary  to  apply  it.  A  more  rapid  and  almost  equally  effective  way  is 
the  hand-bandage  by  the  second  method  (Fig.  45). 

Place  pellets  of  cotton  between  the  fingers,  and  a  fair-sized  tuft  in  the  palm 
of  the  hand.  Take  a  bandage  from  one  to  two  inches  in  width,  carry  it  one  or 
two  turns  around  the  hand  where  the  phalanges  join  the  metacarpus,  until  it  is 
secured,  and  then  by  nicely  adjusted  figure-of-8  turns  (the  crossings  on  the  dorsal 
aspect  of  the  fingers)  cover  the  hand  from  the  tips  of  the  fingers  back.  When 
the  bandage  reaches  the  thumb  in  the  crotch  between  it  and  the  index,  and  begins 
to  roll  up,  it  should  be  clipped  with  the  scissors  deeper  and  deeper  along  the  edge 
nearest  tlie  thumb  with  each  successive  turn  until  the  cut  extends  to  the  middle 
of  the  roller.  Then  a  split  should  be  made  in  the  middle  parallel  with  its  long 
axis,  and  the  thumb  stuck  through  this;  the  next  split  is  nearer  the  distal  edge, 
while  with  the  succeeding  turn  it  may  be  brought  clear  of  the  thumb  on  its  carpal 
aspect.  A  spiral,  with  or  without  the  reverse,  will  hold  on  the  incline  from  the 
thumb  to  the  carpus. 

The  Forearm,  Arm,  and  Shoulder. — From  the  carpus  to  the  elbow  the  spiral 
reverse  or  figure-of-8  will  usually  be  required,  on  account  of  the  pyramidal  shape 
of  the  part.  When  the  elbow  is  reached,  if  the  right-angle  position  (Fig.  46)  is 
determined  upon,  the  figure-of-8  around  the  humerus  and  forearm  will  suffice  to 
climb  along  the  ell)ow;  or  the  simple  spiral,  carried  over  the  same  ground  in  the 
flexure  of  the  joint,  and  gradually  ascending  over  the  convexit}^,  wdl  accomplish 
the  same  purpose.  For  the  arm  the  spiral,  simple  or  reverse,  will'  carry  the  bandage 
to  the  axilla.  When  the  projection  caused  by  the  tendon  of  the  pectoralis  major  is 
reached,  the  roller  is  carried  from  the  inner  side  by  the  front,  over  the  point  of  the 
shoulder,  around  the  back,  and  underneath  the  opposite  arm,  across  the  chest  to 
the  anterior  and  outer  surface  of  the  humerus,  then  underneath  the  arm,  making 
a  figure-of-8  turn,  one  loop  of  which  surrounds  the  arm,  and  the  other  the  thorax. 
These  turns  are  continued,  gradually  ascending  until  the  root  of  the  neck  is  reached. 


BANDAGING 


33 


It  is  best  to  fill  the  axilla  of  both  arms  with  absorbent  cotton  to  prevent  chafing, 
when  this  dressing  is  to  be  worn  for  any  length  of  time. 

The  Toes,  Foot,  Leg,  and  Thigh. — The  great  toe  may  be  bandaged  by  carrying 
a  narrow  roller  spirally  around  it,  from  the  tip  to  the  metatarso-phalangeal  joint, 
and  thence  by  a  figure-of-8  around  the  ankle.  This  last  turn  should  be  several 
times  repeated,  in  order  to  hold  the  dressing  firmly.  It  is  customary  to  include 
all  of  the  toes  in  the  general  foot-bandage. 

To  bandage  the  foot,  begin  by  placing  bits  of  absorbent  cotton  between  the  toes. 
Take  a  roller  from  two  to  two  and  a  half  inches  wide,  and  about  ten  yards  long. 
Lay  the  end  of  the  bandage  parallel  with  the  axis  of  the  leg,  half-way  between  the 
two  malleoli  in  front,  and  carry  the  roller  by  the  inner  side  to  the  heel,  so  that 
the  middle  of  the  bandage  will  be  over  the  center 
of  the  heel's  convexity,  and  on  to  the  starting-point. 
Next,  make  another  turn  around  tlie  ankle,  carrying 


Fig.    45.  —  Figure-of-8   single 
bandage  for  the  liand. 


Fig.  46. — Bandage  for  tlie  slioulder  and  upper  extremity. 


the  posterior  edge  of  the  bandage  over  the  center  of  the  turn  that  has  just  pre- 
ceded it,  and  make  one  or  two  other  turns  in  front  of  this  until  the  heel  is  com- 
pletely covered  (Fig.  47). 

The  bandage  is  then  carried  around  the  heel  in  the  same  direction,  so  that  its 
anterior  border  rests  on  tlie  middle  of  the  first  turn,  and  the  roller  is  carried  from 
the  fibular  side  of  the  heel  across  the  dorsum  of  the  foot  to  the  tibial  side  of  the 
great  toe.  It  then  travels  under  the  bases  of  the  toes  to  the  little  toe,  making  a 
couple  of  complete  turns  around  the  foot  at  this  point,  and,  when  the  roller  has 
again  reached  the  fibular  side  of  the  little  toe,  it  is  made  to  cross  the  dorsum  of 
the  foot  obliquely  to  the  tibial  side  of  the  heel,  keeping  the  lower  edge  of  the 
bandage  about  a  quarter  of  an  inch  above  the  bottom  of  the  heel.  Eepeat  this 
figure-of-8  turn  nntil  the  entire  foot  is  thoroughly  concealed.  It  is  best  to  cut 
with  the  scissors  each  turn  of  the  roller  about  half  through  just  when  it  crosses 
the  front  of  the  ankle,  so  that  the  accumulation  of  the  bandage  at  this  point  may 
not  interfere  with  the  movements  of  the  ankle-joint. 

The  crossings  of  the  figure-of-8  bandage  on  the  dorsum  of  the  foot  should  be 
kept  a  little  to  the  fibular  side  of  the  median  line. 


34 


BANDAGING 


When  the  ankle  is  reached,  the  bandage  should  be  carried  up  the  leg  by  the 
spiral  reverse  until  the  sudden  pronainence  of  the  muscles  of  the  calf  is  reached, 
when,  if  necessary,  the  figure-of-8  reverse  should 
be  practiced  to  just  below  the  knee.  From  this 
point  up  to  the  trochanter  the  simple  figure-of-8, 
spiral,  or  spiral  reverse,  may  be  employed,  accord- 
ing to  the  shape  of  the  limb.  When  the  level  of 
the  gluteal  fold  is  reached,  carry  the  roller 
obliquely  upward  and  outward  about  half-way 
between  the  trochanter  major  and  anterior  iliac 
spine,  on  across  the  sacro-lumbar  region  to  just 


Fig.  47. — Tlie  author's  foot-bandage  with  a  single  roller. 

above  the  upper  margin  of  the  iliac  crest  of  the 
side  opposite  the  limb  being  bandaged,  thence 
downward  across  the  abdomen  and  the  groin  to 
the  front  and  outer  side  of  the  thigh,  and  back 
behind  to  the  inner  side  at  the  point  of  starting. 
This  mancKUvre  is  repeated  until  the  entire  hip 
and  groin  are  covered,  when  the  roller  is  carried  ^^^^^^_ 
spirally  around  the  pelvis  and  abdomen  as  high  %'~~ 
as    the   umbilicus.      The    completed    bandage    is 

shown  in  Fig.  48.  The  portion  of  this  bandage  Y\g.  48. — Hip  and  abdominal  spica  and 
which    goes    around   the    thigh,    groin,    and    pelvis  bandage  for  the  lower  extremity. 

is  called  the  single  spica  for  the  groin,  and  is 

admirably  adapted  to  the  retention  of  a  dressing  upon  a  bubo  or  wound  of  this 
region,  and  also  makes  an  efficient  temporary  compress  for  the  support  of  an 
inguinal  hernia.  A  double  spica  with  a  single  roller  may  be  made  by  carrying 
the  roller,  which  has  already  partially  covered  in  the  groin  and  hip  of  one  side, 
directly  across  the  back  to  a  point  half-way  between  the  trochanter  and  anterior 
iliac  spine  of  the  opposite  side,  over  the  front  of  the  thigh  to  the  inner  side, 
and  thence  behind  and  outward,  describing  a  figure-of-8  around  the  thigh  and 
pelvis  in  a  direction  the  reverse  of  the  preceding  (Fig.  49).  A  modification  of 
this  for  controlling  haemorrhage  after  internal  urethrotomy  is  shown  in  the  chapter 
on  urethrotomy. 

The  aljdomen  and  thorax  should  be  bandaged  by  the  simple  or  reverse  spiral 
until  the  axilla  is  reached  in  the  male,  and  the  mammary  gland  in  the  female. 

To  bandage  the  mammary  gland  it  is  best  to  place  a  thin  layer  of  absorbent 
cotton  over  this  organ,  and  under  the  axilla  as  well.  The  roller,  about  three  inches 
wide,  should  be  carried  two  or  three  times  around  the  thorax  just  below  the  breast, 
which,  if  pendulous,  should  be  lifted  well  up  toward  the  clavicle.  If  the  right 
breast  is  to  be  bandaged,  the  operator,  standing  in  front,  should  carry  the  roller 


BANDAGING 


35 


from  the  patient's  right  to  the  left  side,  around  the  body,  and  then  obliquely 
upward  across  the  front  of  the  chest,  catching  the  under  surface  of  the  gland, 
passing   over   the   left   clavicle,    making    a   figure-of-S    around    the   shoulder    and 


Fig.  49. — Double  spica.     (After  Fischer.)  Fig.  50. — Bandage  for  support  and  com- 

pression of  the  brea.st.    (After  Fischer.) 

axilla,  and  then  across  the  back  to  the  starting-point  (see  Fig.  50).  It  is  now 
carried  directly  around  the  chest,  and,  when  the  circuit  is  completed,  again  travels 
obliquely  itpward  on  a  plane  about  one  inch  higher  than  the  preceding  turn.  This 
is  repeated  until  the  organ  is  entirely  covered.    When  both  breasts  require  support, 

the  second  may  be  bandaged  in  the  same 
way  by  an  additional  roller,  or,  as  shown 
in  Fig.  51,  a  single  bandage  may  be  thrown 
around  the  thorax  and  neck  in  figure-of-8 
fashion,  so  as  to  support  both  organs. 


Fig.  51. — Double  bandage  for  the  breasts. 
(After  Fischer.) 


Fig.  52. — The  hood-bandage. 


Bandages  for  the  Head  and  Face. — For  retaining  ice-caps,  or  other  dressings 
to  the  head,  the  hood-bandage  will  be  found  convenient,  while  its  modifications  will 
sufBce  to  keep  a  dressing  upon  any  limited  portion  of  the  scalp  (Fig.  52). 

To  apply  this,  take  a  roller  twelve  yards  long  and  two  and  a  half  inches  in 
width,  rolled  from  both  ends  to  the  center.     Holding  one  head  of  the  roller  in 


36 


BANDAGING 


each  hand,  the  surgeon,  standing  behind  the  j^atient  and  laying  the  middle  of  the 
bandage  across  the  forehead  just  over  the  eyebrows,  carries  one  roller  in  the  right 
and  the  other  in  the  left  hand  around  the  head,  above  the  ears,  and  crosses  them 
under  the  occiiDut,  so  that  the  roller  which  went  to  the  rear  in  the  left  hand  will 
travel  again  to  the  front  over  the  same  path.  The  roller  in  the  right  hand  is  then 
carried  over  the  head,  in  the  median  line,  from  the  occiput  to  the  nose,  and  at  this 
point  it  is  caught  and  held  down  by  the  encircling  turn  carried  in  the  left  hand. 
Then  carry  the  roller  wliich  came  over  the  median  line  of  the  head  back  again 
to  the  rear,  so  that  its  right  edge  will  rest  on  the  middle  of  the  first  turn.  It  is 
again  caught  under  the  encircling  turn  at  the  occiput,  is  carried  to  the  front  on 
the  opposite  side,  and  continues  to  travel  from  before  backward  in  an  ellipse 
that  is  constantly  increasing,  until  it  blends  with  the  encircling  turn  upon  the 
sides  of  the  head,  near  the  ears.  Each  successive  turn  of  the  elliptic  should 
leave  about  one  third  of  the  turn  that  preceded  it  uncovered  in  the  center.  Of 
course,  the  ends  will  meet  at  the  same  point,  before  and  behind,  where  the  reverses 
are  made. 

If  it  is  only  recpiired  to  maintain  a  dressing  in  the  median  line  of  the  scalp,  it 
will  suffice  to  carry  a  circular  turn  or  two  around  tlie  head,  just  above  the  eyebrows 
and  ears,  and  below  the  occiput,  while  an  antero-posterior  strip  is  pinned  to  this  in 
front  and  behind. 

The  Head  and  Chin  Bandage  (Fig.  53)  may  be  made  to  serve  several  purposes 
— namely,  to  retain  a  dressing  on  the  chin  and  lower  face,  the  same  upon  the  scalp 
at  any  portion,  and  also  for  temporary  fixation  of  the  lower  jaw  after  fracture  of 
this  bone.     It  is  applied  as  follows: 

The  end  of  a  bandage  from  one  inch  and  a  half  to  two  inches  in  width  is  held 
about  half-way  between  the  left  ear  and  the  occipital  protuberance,  while  the  roller 
is  carried  to  the  front  and  oljliquely  across  the  heacl,  just  in  front  of  the  right 
ear,  under  the  chin,  ujj  in  front  of  the  left  ear,  then  across  the  scalp,  passing 
backward  l^etween  the  right  ear  and  occiput  to  beneath  this  protuberance,  when 
it  is  carried  beneath  the  left  ear  straight  across  the  front  or  labial  aspect  of 
the  chin,  and  around  by  the  right  side  to  the  point  of  commencing.  This  ma- 
noeuvre  shoukl   he  repeated   several  times,   and   the   dressing   then   completed   by 


Fig.  .54. — Compre.ssion  bandage  for  arrest  of  hcem- 
orrhage.      (After  Berkeley  Hill.) 

carrying  the  roller  twice  around  the 
head  aliove  the  ears  and  eyebrows,  and 
l)eneath  the  occiput,  and  pinning  a  strip 
along  the  median  line  of  the  scalp  at 
the  various  j)oints  where  the  turns  cross 
each  other. 
Knotted  Bandage. — This   dressing    (Fig.    54)    is   sometimes   employed  in   the 

arrest   of   hemorrhage   from   wounds   of   the   temporal   and   other   vessels   of   the 

scalp. 

Take  a  piece  of  cork  or  wood,  al)ont  an  inch  in  diameter  and  one  quarter  of  an 


-Head-stall   and  bandage  for  fracture 
of  the  lower  jaw. 


B-\XDAGIXG 


37 


inch  in  thickness,  and  wrap  it  with  sublimate  gauze  or  lint  to  make  a  compress. 
Apply  this  to  the  bleeding  point,  and  lay  over  it  the  center  of  a  double-headed 
roller,  carrying  the  turns  around  the  head,  alcove  the  ears.  They  are  then  crossed 
over  the  compress,  one  end  is  carried  tmder  the  chin,  the  other  over  the  top  of  the 
head,  and  are  again  crossed  on  the  opposite  temple.  Having  carried  the  rollers 
again  around  the  head,  and  crossed  them  firmly  over  the  compress,  the  ends  are 
pinned  securely  and  cut  off.  A  horizontal  slip  may  then  be  pinned  to  the  anterior, 
middle,  and  posterior  slips  of  the  knotted 
bandage,  beginning  in  the  median  line 
on  the  forehead,  then  back  to  the  center  ly; 


Fig.  .56. — Handkerchief  bandage. 


-Bandage  for  the  eye  and  upper  lip. 
(After  Esmarch.) 


of  the  middle  slip,  and  then  to  the  slip 
imderneath  the  occiput,  to  hold  the 
dressing  securely  in  position. 

To  bandage  the  eye  (the  left,  for  example),  hold  the  end  of  the  strip  half-way 
between  the  right  ear  and  occiput,  and  bring  the  roller  forward  over  the  left  eye 
and  malar  eminence,  and  around  backward  beneath  the  ear  and  occiput  to  the  point 
of  starting,  and  repeat  once,  ^lien  the  second  turn  arrives  at  the  right  ear  it 
should  pass  above  this  and  completely  around  the  skull.  Just  above  the  eyebrows  and 
below  the  occiput,  in  order  to  secure  the  oblique  turn.  Complete  the  dressing  by 
alternating  between  the  horizontal  and  the  oblique  di- 
rection of  the  roller  (Fig.  5-5). 

For  the  upper  lip  a  dressing  is  readily  secured  by  a 
narrow  bandage  passing  horizontally  around  beneath  the 
nose  and  ears,  and  held  in  place  by  the  head-staU  at- 
tachment, as  in  Fig.  53. 

Handkerchief  Bandages. — In  addition  to  the  fore- 
going, emergency  dressings  for  different  parts  of  the 
body  may  be  extemporized  from  pieces  of  cloth  cut  in 
various  shapes — the  so-called  handl-erchief  bandages. 

Head  and  Face. — A  simple  hood  (Fig.  56)  may  be 
made  as  follows :  A  piece  of  soft  musUn  is  cut,  27  by  23 
inches,  folded  over  for  6  or  7  inches  along  its  greatest 
measurement,  and  laid  upon  a  table,  with  the  short 
piece  underneath.  Place  the  index-finger  at  the  middle 
of  the  folded  edge,  and  turn  the  nearest  comers  toward 
the  center,  forming  a  p^Tamid.'  Xow  roll  the  remaining  straight  edge  up  imtil 
it  is  on  a  level  vrith  the  edge  which  was  turned  under,  and  place  upon  the  head, 
so  that  this  edge  will  be  put  above  the  eyebrows,  while  the  rolled  portion  comes 
across  the  occiput,  and  the  ends  are  pinned  beneath  the  chin.  The  conical  tip 
may  be  pinned  down  if  desired. 


Fig.  57. — Four-tailed  bandage. 


38 


BANDAGING 


The  foitr-iailed  cap  is  made  from  a  piece  of  muslin,  45  inches  long  by  10  wide, 
split  from  each  end  to  within  4  inches  of  the  center.  Each  of  the  four  tails  is  5 
inches  in  width.  Lay  the  center  of  the  piece  across  the  vertex,  carry  the  posterior 
tails  forward  over  the  ears,  and  tie  them  under  the  chin  and  the  anterior  backward 
beneath  the  occiput  (Fig.  57). 

The  head  and  face  hood  is  made  as  follows:  A  piece  of  soft,  light  cloth,  40 
inches  square,   is   folded  and  laid   across   the  head  in   such   a   manner  that   the 


Fig.  58. — Head  and  face  hood.     (After  Esmarch.) 


Fig.  59. — The  same  completed.     (After 
Esmarch.) 


shortest  fold  which  is  on  top  comes  to  the  level  of  tlie  eyebrows,  while  the  longer 
reaches  to  the  tip  of  the  nose  (Fig.  58).  The  corners  belonging  to  the  fold  which 
is  parallel  with  the  line  of  the  eyebrows  are  tied  snugly  beneath  the  chin.  The 
longer  fold  is  now  turned  wp  to  the  level  of  the  eyebrows,  while  the  corners  belong- 
ing to  it  are  drawn  forward  until  freed,  and  are  then  carried  back  and  tied  beneath 
the  occiput  (Fig.  59). 

For  holding  an  ice-bag  or  dressing  upon  the  head,  the  shull-net  (Fig.  60)  will 
be  found  of  use.     It  is  made  of  cotton  threads,  is  tightened  around  the  head  by  a 


Fig.  60. — Ice-bag  net.      (After  Esmarch.) 


Fig.   61. — Four-tailed   bandage   for  fracture  of 
the  lower  jaw. 


tape,  which  draws  it  together  like  the  strings  of  a  reticule,  and  is  further  secured 
by  a  strap  tied  under  the  chin. 

The  four-tailed  dressing  for  the  chin  and  lower  jaw  is  made  by  splitting  a 
strip  of  muslin,  6  inches  wide  and  45  inches  long,  from  each  end  to  ^^dthin  1^ 


BANDAGING  39 

inches  of  the  center,  placing  its  middle  over  the  chin,  and  turning  the  posterior  tails 
upward  in  front  of  the  ears  to  be  tied  over  the  vertex.  The  anterior  tails  are  now 
carried  back  below  the  ears,  crossed  once,  and  pinned  beneath  the  occiput,  while 
the  ends  are  carried  upward  and  forward  and  tied  upon  the  forehead  (Fig.  61). 

Other  special  dressings  will  be  described  in  the  chapters  on  Eegional  Surgery. 

The  T  bandage,  made  by  sewing  the  end  of  one  piece  of  muslin,  7  inches  wide 
and  about  4  feet  long,  to  the  middle  of  a  second  piece  of  the  same  width  and  about 
5  feet  in  length,  is  essential  in  holding  a  dressing  over  the  anal  or  perineal  region. 
One  belt  is  fastened  around  the  waist  and  the  tail  brought  between  the  legs  and 
pinned  in  front  to  the  belt.  For  abdominal  dressings  a  wide  piece  of  muslin  may 
be  snugly  drawn  and  pinned  around  the  body. 


CHAPTEK   IV 

H^MOEIiHAGE,    WOUNDS,    AND    "WOUND    SUTURE 

Repair  and  the  Occlusion  of  the  Arteries.    Process  of  Repair.    Method  of  Suturing.    Intravenous 
Infusion.     Poisoned  Wounds.     Snake  Bites. 

H^^MOEEHAGE  is  aHerial,  capillary,  and  venous.  Occurring  with  the  injury, 
it  is  primary.  Secondary  hsemorrhage  occurs  during  the  process  of  repair,  and 
usually  after  infection. 

The  natural  arrest  of  hgemorrhage  may  result  from  the  contraction  and  retrac- 
tion of  divided  vessels  and  the  formation  of  coagulum.  Diminution  in  the  volume 
of  blood  and  weaker  heart  action  favor  the  formation  of  clot.  In  certain  condi- 
tions, as  in  atheroma  of  the  vessel  walls  and  in  some  tissues  (as  the  tongue,  scalp, 
bone),  vascular  retraction  and  contraction  is  insufificient,  and  hemorrhage  is  more 
apt  to  be  continuous,  unless  arrested  by  the  ligature  or  by  compression. 

The  surgical  means  for  the  arrest  of  haemorrhage  are: 

1.  Direct  compression  of  the  bleeding  surface  with  a  clean  towel  or  any  soft 
aseptic  material. 

2.  Compression  over  the  artery  of  supply  above  and  of  the  vein  below  the  bleed- 
ing point. 

3.  Elevation,  when  the  haemorrhage  is  from  an  extremity,  or  the  upright  posture 
when  from  the  head  or  neck. 

4.  Constriction  with  a  handkerchief,  towel,  belt,  or,  preferably,  piece  of.  rubber 
tubing  or  Esmarch  bandage  over  the  artery  of  supply  above  the  seat  of  injury.  If 
the  hffimorrhage  be  only  venous,  compression  should  be  made  on  the  distal  side. 

6.  When  the  haemorrhage  is  from  the  trunk  and  the  bleeding  point  cannot  be 
immediately  reached  by  operation,  pressure  may  be  taken  from  the  bleeding  point 
by  constricting  the  arms  near  the  axilla  and  the  thighs  near  the  crotch  with  band- 
ages tightened  suflficiently  to  check  the  venous  current,  while  they  permit  the  flow 
of  blood  through  the  artery.  This  facilitates  coagulation  at  the  bleeding  point. ^ 
When  the  bleeding  is  arrested,  the  bandages  should  be  carefully  loosened,  one  at 
a  time,  to  prevent  a  sudden  influx  of  a  large  volume  of  blood,  which  might  dislodge 
the  clot. 

6.  Hot  or  cold  applications.  After  an  injury  or  during  an  operation,  capillary 
oozing  may  be  controlled  or  arrested  by  elevation  of  the  bleeding  part,  flushing  with 
hot  water  or  salt  solution  (120°  E.,  or  about  as  hot  as  the  submerged  hand  can 
endure) ,  or  by  compression  with  towels  dipped  in  the  hot  solution.  If  heat  cannot 
be  obtained,  cold  in  the  shape  of  ice  or  very  cold  water  may  be  substituted. 

7.  Torsion  and  the  ligature.  During  a  surgical  operation  the  artery  forceps 
is  chiefly  relied  upon  to  control  bleeding.  Vessels  seen  in  the  course  of  a  dissection 
should  lie  clamped  on  either  side  with  and  divided  between  the  forceps.  The  vessel 
should  be  at  once  occluded  by  torsion  or  the  ligature.  In  applying  a  forceps  no 
more  tissue  should  be  caught  in  the  grasp  of  the  instrument  than  is  necessary  to 
secure  the  vessel.  By  applying  a  number  of  instruments,  much  time  can  be  saved 
in  an  operation,  since  smaller  bleeding  points  are  permanently  occluded  by  per- 
mitting the  forceps  to  remain  in  place  from  ten  to  twenty  minutes.  In  general, 
only  a  small  proportion  of  the  forceps  applied  in  the  course  of  an  operation  require 

«  Method  of  Detmold. 
49 


ILE.MORRIL\GE,    WOUXDS,   AXD   WOUXD   SUTURE  41 

the  ligature.  Twisting  a  small  vessel  for  five  or  six  rotations  is  an  excellent  and 
rapid  method  of  arresting  hsemorrhage.  Properly  applied  retraction,  without  in- 
juring the  tissu.es,  will  control  and  may  permanently  arrest  bleeding  in  the  track 
of  the  incision. 

For  the  larger  vessels  or  bleeding  points,  and  in  all  operations  within  the  cavi- 
ties, the  ligature  is  the  chief  reliance  of  the  surgeon.  Catgut  and  silk  or  linen 
thread  are  commonly  used.  Plain  catgut  will  usually  suffice,  though  in  tying  the 
larger  vessels  (carotids,  iliacs,  and  femorals),  ten-day  chromicized  gut  is  preferaljle. 
Linen  or  silk  is  chieflj'  relied  upon  in  tsdng  pedicles  or  larger  masses  traversed  bj^ 
good-sized  vessels,  especially  in  abdominal  work. 

In  tving  a  branch  of  a  vein  close  to  the  parent  trunk,  or  in  applying  a  lateral 
ligature  to  a  vein,  verj-  fine  silk  or  linen  thread  should  be  used.    In  operations  where 


Fig.  02. — Reef  knot.  Fig.  63. — False  knot.  Fig.  64. — Friction  knot. 

the  vessels  are  friable,  as  in  the  extirpation  of  goitre,  silk  or  linen  may  at  times 
be  preferred.  In  tying  the  exposed  ends  of  a  divided  artery,  these  should  be  seized 
with  dissecting  forceps,  and  drawn  out  so  that  the  ligature  may  be  thrown  around 
the  vessel  and  its  sheath  one  quarter  of  an  inch  from  the  end.  Bj'  this  precaution 
not  infrequently  a  small  collateral  branch  is  caught,  which  otherwise  would  require 
a  second  ligature.  Provided  contiguous  nerves  are  eliminated,  it  is  not  objection- 
able to  include  a  certain  amount  of  extravascular  tissue  in  the  grasp  of  the  ligature. 
In  arterial  degeneration  (sclerosis,  atheroma,  calcareous  deposits)  this  practice  is 
necessary  to  prevent  the  ligature  from  cutting  through.  On  many  occasions  the 
author  has  included  a  large  vein  and  arterv'  (as  the  femoral)  in  the  same  ligature. 


Fig.  65. — Traumatic  endarteritis.  Section  from  the  common  carotid  of  a  horse,  tied  with  a  broad  nerve 
Ugature,  showing  at  B  B  the  proliferation  of  the  intima.  The  inflammatorj-  new  formation  is  pro- 
jected into  the  lumen  of  the  vessel,  and  lias  caused  partial  atrophy  of  the  media,  C:  A  B,  the  intima; 
B  B,  portion  of  the  intima  in  the  grasp  of  the  ligature;  D,  the  adventitia,  slightly  changed,  with 
small-ceU  infiltration.  (Drawn  by  Dr.  W.  L.  Wardwell,  from  the  author's  specimen.  Magnified 
about  forty  diameters.) 

The  tension  should  be  such  that  the  occlusion  is  complete  and  the  ligature 
buried  deeply  enough  to  prevent  slipping.  The  reef-knot  Ugature  (Pig.  62)  wiU 
usually  hold,  although  occasionally  the  friction,  hnot  (Fig.  64)  may  be  required  to 
prevent  the  first  loop  from  slipping.     This  danger  may,  however,  be  entirely  elim- 


42  HAEMORRHAGE,   WOUNDS,   AND   WOUND   SUTURE 

inated  by  grasping  the  first  turn  of  the  ligature  with  a  pair  of  smooth  forceps  (the 
author's  ligature  forceps),  which  holds  the  first  loop  secure  until  the  second  is 
tightened. 

In  tying  a  vessel  in  continuity,  the  ligature  is  usually  passed  by  the  aneurism 
needle  within  the  sheath,  but  this  is  immaterial,  provided  all  contiguous  nerves  or 
other  structures  are  excluded.  Tightening  the  ligature  just  enough  to  arrest  the 
passage  of  blood  will  suffice.  A  division  of  the  inner  coats  by  the  ligature  is  not 
essential  to  permanent  occlusion.  The  author  first  demonstrated  in  1883  that  a 
clot  had  nothing  to  do  with  permanent  vascular  occlusion  after  the  ligature,  but 
that  this  process  was  the  result  of  cell  proliferation  and  the  organization  of  a  new 
connective  tissue,  which  by  fibrillation  made  a  permanent  cicatricial  occlusion.  ^  In 
tying  arteries  in  the  flaps  of  an  amputation,  the  ligature  must  be  drawn  very  tight 
to  prevent  the  jDossibility  of  slipping. 

Wounds 

A  woimd  is  a  suddeii  solution  of  continuity  in  the  soft  tissues  of  the  body ;  such 
lesions  in  bone  or  cartilage  are  fractures. 

Wounds  are  operative  and  accidental,  and  may  be  classed  under  four  heads : 
incised,  punctured,  lacerated,  and  contused.  When  inoculated  with  a  virus  or 
venom,  as  in  snake  bite,  they  are  poisoned  wounds.  Injuries  from  missiles  pro- 
jected by  guns  demand  especial  consideration  as  gunshot  wounds. 

An  incised  wound  is  made  by  a  clean  cut  with  a  sharp  instrument;  a  punctured 
wound,  by  a  narrow  instrument  which  does  not  cut  laterally;  a  lacerated  wound, 
by  a  dull  instrument  which  tears;  while  in  contused  wounds  the  tissues  are  more 
bruised  than  divided. 

When  the  soft  tissues  are  divided,  capillaries,  arterioles,  and  venules  contiguous 
to  the  injury  instantly  contract,  and  immediately  thereafter  become  dilated  beyond 
their  normal  caliber.  The  divided  tissues  retract,  the  intervening  space  fills  with 
blood,  and  if  no  large  vessels  are  divided,  hEemorrhage  may  be  arrested  spontaneously 
by  coagulation.  The  chief  factor  in  rapid  coagidation  is  the  leucocyte,  the  number 
of  which  is  vastly  increased  within  the  irritated  zone.  The  paraglobulin  of  these 
corpuscles  combines  with  the  fibrinogen  of  the  blood  plasma,  not  only  in  the  blood 
extravasated,  but  in  the  lumen  of  the  capillaries  and  other  vessels  from  the  surface 
of  the  wound  to  the  nearest  anastomosis. 

From  this  period  on  the  changes  which  occur  in  the  process  of  repair  vary 
with  the  presence  or  absence  of  septic  organisms.  In  aseptic  wounds,  while  there 
can  be  no  reunion  of  atom  to  atom  with  resumption  of  function  without  cell  pro- 
liferation, this  process  takes  place  with  the  minimum  of  disturbance  and  with  the 
restoration  of  the  maximmn  of  function.  If  the  hasmorrhage  is  entirely  arrested, 
the  wound  thoroughly  dried  under  aseptic  precautions,  the  parts  brought  together 
by  properly  adjusted  pressure  from  deep  as  well  as  superficial  absorbable  sutures, 
the  surface  of  the  skin  carefully  dried  and  immediately  coated  with  a  thick  layer 
of  sterile  collodion,  the  changes  which  the  tissues  imdergo  in  the  effort  to  restore 
their  integrity  include;  with  hyperasmia,  an  increased  number  of  leucocytes,  and 
their  diapedesis  (or  passage  from  the  vessels  through  their  walls  to  wander  in  the 
intervascular  spaces),  and  general  cell  proliferation.  Vascular  buds  project  them- 
selves from  the  proliferating  endothelial  cells  of  the  blood  vessels  (capillaries)  at 
their  divided  and  occluded  ends,  which,  meeting  those  from  opposing  surfaces,  unite 
to  form  new  vessels.  In  like  manner,  from  the  original  cells  which  composed  other 
divided  tissues,  nerve,  connective  tissue,  epithelial,  etc.,  new  cells  are  thrown  out. 
In  from  five  to  ten  days  the  process  of  contraction  begins,  and  some  of  the  new 
blood  vessels  may  be  obliterated  by  this  normal  process  of  connective-tissue  fibrilla- 
tion. In  the  process  of  repair,  under  aseptic  conditions,  any  excess  of  new  tissue 
undergoes  granular  metamorphosis.  When,  however,  infection  occurs,  liquefaction 
of  the  new  embryonic  tissue  (suppuration)  takes  place  in  varying  degree.  The 
process  of  repair  is  prolonged,  cicatrization  or  fibrillation  is  increased,  and  the 
restoration  of  function  less  complete.  By  cicatrization  much  of  the  vascular  supply 
is  obliterated,  giving  the  bleached  appearance  common  to  scar  tissue,    In  an  open 


HEMORRHAGE,   WOUNDS,   AND   WOUND   SUTURE 


43 


granulating  wound  in  which  the  edges  are  not  too  widely  separated,  a  new  integu- 
ment is  formed  by  the  projection  of  epithelium  from  the  edges. 

Treatment. — The  arrest  of  hemorrhage  is  the  first  indication.  The  methods 
have  already  been  described. 

In  closing  a  wound  by  sutures,  the  points  of  chief  importance  are  to  bring  all 
parts  of  the  opposing  surfaces  in  apposition  with  moderate  pressure  equally  dis- 
tributed; overpressure,  especially  in  the  skin,  produces  pain  and  impairs  nutrition. 


:4 


W  "1 


i-f^- 


Fig.  67. — Alternating  deep 
and  superficial  sutures. 


No  clot,  serum,  or  dead  tissue  should  be  left,  since  these  encourage  the  proliferation 
of  septic  organisms.  AVhen  oozing  cannot  be  controlled,  a  temporary  catgut  drain 
should  be  inserted.  These  absorbable  drains  are  made  preferably  of  ten-day  chromic- 
aeid  catgut,  with  the  strands  from  ten  to  fifty  in  number,  parallel,  not  tivisted. 

When  possible,  drainage  should  always  be  by  gravitation  from  the  most  de- 
pendent portion  of  a  wound  as  the  patient  rests  in  bed.  The  edges  of  the  wound, 
through  the  skin,  should  be  carefully  brought  in  apposition ;  and  to  avoid  a  scar, 
especially  upon  the  face  or  other  exposed  surfaces,  the  very  finest  needles  and 
silk-  or  linen-suture  material  should  be  used. 

In  closing  shallow  wounds,  it  will  suffice  to  enter  the  needle  one  eighth  of  an 
inch  from  tlie  ed-o.  and  out  at  the  same  distaneo  from  the  opposite  margin,  as 


^ 


'"^^   I 


Fig.  69. — A  mattress  suture. 


Fig  70  —Quill  or  lead-plate  su- 
ture rarely  employed  except 
in  cleft-palate  operations. 


Fig.  71.— Silve 
suture. 


shown  in  the  interrupted  suture  (Fig.  66).  For  rapid  work  the  continuous  suture 
(Fig.  68)  is  more  frequently  employed  on  unexposed  surfaces.  In  tying  a  suture 
the  edges  of  a  wound  should  be  brought  together  with  Just  sufficient  tension  to 


44 


HiEMORRHAGE,   WOUNDS,   AND   WOUND   SUTURE 


approximate  and  hold  them  in  contact  without  bleaching  or  wrinkling.  Infolding 
should  be  avoided.  Silkworjn  gut  makes,  in  general,  one  of  the  cleanest,  most 
aseptic,  and  reliable  suture  materials  for  the  skin. 

In  approximating  a  tliree-cornered  wound,  the  methods  shown  in  Figs.  73  and 
73  are  useful.  Many  superficial  small  wounds  may  be  closed  and  held  together  by 
pressure  with  the  fingers  until  collodion  has  been  applied  and  allowed  to  harden. 
This  dressing  alone,  or  at  times  supjjorted  by  narrow  adhesive  strips,  will  render 
suturing  vmnecessaiy.  Small  metal  clips  (Michel),  which  partially  perforate  the 
skin  and  hold  the  edges  of  the  incision  in  apposition,  are  j^referred  to  sutures  by 
some  operators.  For  general  work,  however,  the  suture,  properly  employed,  is  the 
better  method. 

A  subcuticular  suture  of  silkworm  gut  may  be  used  with  great  advantage  in 
the  rapid  closure  of  extensive  operative  wounds.     It  is  inserted  as  follows : 

The  needle,  being  made  to  enter  through  the  skin  about  one  quarter  of  an  inch 
from  the  ujjper  end  of  the  incision  and  to  come  out  in  the  wound,  is  carried  through 


Fig.  74. — Showing  the  ranning  subcutaneous  catgut 
suture  which  has  approxiniated  the  tliiclv  layer  of 
fat  and  tlie  subcuticular  suture  of  silkworm  gut 
which  is  being  inserted.      (Charles  P.  Noble.) 


Fig.  75. ; —  Apparatus  for  the  intraven- 
ous infusion  of  normal  salt  solu- 
tion. 


the  edge  of  the  true  skin  (the  eorium)  on  one  side  for  one  quarter  of  an  inch, 
thence  directly  across  to  the  opposite  side,  where  it  is  inserted  for  the  same  distance, 
and  so  on  in  zigzag  fashion  for  the  entire  length  of  the  incision  until  the  suture 
is  brought  out  through  the  skin  just  beyond  the  lower  angle  (Fig.  74).  Drawing 
upon  the  two  exposed  ends  in  different  directions  approximates  the  cut  surfaces 


aaaioRRHAGE,  wounds,  and  wound  suture  45 

throughout  their  extent.  These  ends  should  he  loosely  tied  over  a  swab  or  other 
dressing  laid  upon  the  wound. 

Suture  needles  are  of  various  patterns  and  sizes :  straight,  curved,  half  curved, 
angular,  etc.  Those  without  cutting  edges  are  preferable  (round  embroidery  needles 
and  the  modified  Hagedorn).  For  rapid  work,  long  half-curved  needles,  large 
enough  to  be  used  without  a  needle  holder,  are  essential. 

HcemorrJiage. — Should  Ijleeding  l)e  so  profuse  that  sjTicope  is  imminent,  the 
head  should  be  lowered  so  that  gravity  maj^  carry  enough  blood  to  the  Ijrain  to 
maintain  its  function.  The  administration  of  whisky  by  the  mouth  or  rectum  or 
hypodermically  is  indicated.  A  tablespoonful  or  more  of  black  coffee  may  be  ad- 
ministered jDer  rectum  with  the  whislr\% 

Intravenous  injection  of  normal  salt  solution,  heated  to  about  110°-115°  F., 
should  be  done.  The  quantit]^  thrown  in  will  l}e  determined  by  the  improvement 
in  heart  action,  as  shown  hj  the  pulse.  One  or  two  pints  will  usuall}'  suffice, 
though  twice  this  quantity  nia_y  be  used.  When  con-s-enient,  an  open  vein  should 
be  utilized,  or  the  median  basilic  or  cephalic  near  the  elbow  may  be  exposed  and 
the  pipette  inserted  under  cocaine  analgesia. 

A  simjjle  apparatus  for  infusion  is  shown  in  Fig.  75.  It  consists  of  a  glass 
funnel,  to  the  tip  of  whicli  a  ru1)ber  tube  is  attached,  while  at  the  end  of  the  tube 
is  a  canula  for  introduction  into  the  vein.  The  funnel  should  be  filled  and  a 
certain  quantity  allowed  to  run  through  to  exchide  the  air.  The  stopcock  is  now 
closed  or  the  rubber  titbe  compressed,  holding  the  canula  and  tube  full  of  fluid. 

When  the  canula  is  carried  into  the  vein,  it  should  he  held  in  place  by  a  ligature 
tied  around  it  and  the  vessel.  The  introduction  should  he  slowly  and  gradually 
accomplished.  By  keeping  the  fttnnel  filled  with  tlie  sohition,  no  air  can  enter. 
The  effect  upon  the  heart  is  at  once  noticeable.  The  pulse  is  reduced  in  the  numljer 
of  beats  and  increased  in  force.  If  the  apparatus  described  is  not  at  hand,  a 
fountain  syringe  which  has  been  carefully  sterilized  by  boiling  ma}'^  he  substituted. 
A  pocket-case  canula  or  an  ordinary  glass  medicine  dropper  will  suffice  as  a  suId- 
stitute  for  the  special  transfusion  canula. 

This  method  has  jiractically  superseded  the  direct  transfusion  of  blood.  When 
the  condition  of  the  patient  is  not  extreme,  the  salt  sohition  may  be  injected  into 
the  subcutaneotts  fat. 

Poisoned  ^Yonnds — Snalce  Bite. — The  prognosis  in  snake  bite  is  grave  in  pro- 
portion to  the  source  of  the  venom  and  the  quantity  and  rapiditv^  of  introduction. 
That  of  the  cohm  in  India  is  considered  almost  inevitably  fatal,  while  the  rattle- 
snal'e  is  classed  with  the  more  venomous  reptiles  of  this  country. 

"\Mten  the  venom  is  lodged  in  the  skin  or  subcutaneous  tissues,  where  absorp- 
tion takes  place  through  the  lymph  vessels  and  capillaries,  the  prognosis  is  more 
favoralile  tlian  when  the  fang  pierces  a  vein. 

The  order  of  toxicit}^  in  serpent  venom,  so  far  as  known  at  this  date,  is  as 
follows:  1.  Cobra  (Naia  tripudians) ,  a  native  of  India;  rattlesnake  (Crofahis 
durissus  and  C.  adamant eus) ,  of  southern  Xorth  America;  Bothrop  jararacassa 
and  B.  jararaca,  closely  allied,  according  to  Dr.  Eobert  Fletcher,^  in  the  intensity 
of  its  venom  to  its  congener,  the  ?^orth  American  rattlesnake;  American  copper- 
head {TrigonocephaJus  contortrix) ;  the  American  moccasin  (Toxicophis  atrapiscus 
and  r.  piscivorus)  ;  the  spreading  adder,  of  the  order  Yipera  hems. 

The  venom  of  snakes  is  excreted  by  a  gland  situated  near  the  eye.  In  the 
act  of  striking  or  biting  it  is  forced  by  a  compressor  muscle  along  a  channel,  or 
groove,  in  the  fangs.  In  the  quiescent  state  the  fangs  (one  on  either  side)  are 
folded  Imckward,  and  are  buried  in  grooves  in  the  mucous  membrane  of  the  roof 
of  the  mouth.  When  ready  for  use,  they  are  dra'^vn  forward  by  erector  muscles. 
Rattlesnake  venom,  according  to  Dr.  S.  Weir  Mitchell,-  has  a  specific  gravitv  of 
1.044,  and  an  invariably  acid  reaction.  Its  color  is  from  a  greenish  to  a  straw 
tint.  Conjointly  with  Dr.  Edward  T.  Eeichert,^  he  has  isolated  three  proteids — 
namely,  venom  peptone,  venom  glolmlin,  and  venom  albumen.     Venom  globulin  is 

'  "American  Journal  of  the  Medical  Sciences,"  July,  1883. 

2  Smithsonian  Contributions,  1860.     "New  York  Medical  Journal,"  1868. 

'  "Philadelphia  Medical  News,"  1883, 


46  ILEMORRHAGE,  WOUNDS,  AND  WOUND  SUTURE 

intensely  toxic,  producing  rapid  extravasations  of  blood;  venom  peptone  is  less 
poisonous,  but  produces,  when  injected  into  the  breasts  of  pigeons,  intense  slough- 
ing. The  albumen  venom  is  not  yet  fully  understood.  Bromine,  iodine,  sodiimi, 
and  potassium  hydrate  and  potassium  permanganate  destroy  chemically  the  toxic 
property  of  the  venonr  of  the  rattlesnake,  copperhead,  and  moccasin.  Serpent  venom 
produces  no  poisonous  effect  in  the  tissues  of  the  reptile  which  produces  it,  or  in 
the  tissues  of  any  venom-producing  reptile.    It  is  poisonous  to  non-venomous  snakes. 

Pain  of  a  sharp  or  stinging  character  is  usually  felt  in  the  wound.  Fright  or 
shock  may  mask  this  symptom.  Swelling  rapidly  ensues,  and  in  rattlesnake  bite 
ecchymosis  is  not  uncommon.  The  swelling  extends  in  all  directions,  but  is  most 
marked  in  the  line  of  the  lymphatics  toward  the  center.  Headache,  fever,  rigors, 
irregular  breathing,  and  a  low,  feeble  pulse,  with  nausea,  may  be  present.  Adenitis, 
abscess,  or  sloughing  usually  occur.  If  death  does  not  ensue,  the  case  may  ter- 
minate favorably  in  two  or  three  days,  or  last  for  weeks  and  months. 

Treatment. — Suck  the  venom  from  the  wound  at  once,  constricting  the  member 
between  the  wound  and  body  to  retard  absorption,  and  quickly  apply  a  tight  liga- 
ture or  tourniquet.  Make  a  free  crucial  incision,  and  again  use  labial  suction. 
As  soon  as  jjossible,  and  before  the  tourniquet  is  released,  infiltrate  into  the  tissues 
within  a  radius  of  an  inch  from  the  markings  of  the  fangs  a  free  quantity  of  per- 
manganate-of-potash  solution  (for  the  rattlesnake,  gr.  x  to  xv  to  §j  of  water,  and 
for  the  cobra,  gr.  xxv  to  gj).     Whisky  is  advised  as  a  cardiac  stimulant  in  adults. 

Within  a  recent  period  experiments  have  encouraged  the  hope  that  a  serum 
has  been  produced  which  neutralizes  the  deadly  effects  of  serpent  venom.  That 
for  the  cobra  and  the  rattlesnake  are  already  reported  as  successful  demonstrations. 
Unfortunately,  these  agents  are  not  easily  obtainable,  and  the  more  ready  methods 
will  have  to  be  employed. 

When  great  swelling  occurs,  and  gangrene  is  threatened  on  account  of  tension, 
free  incisions  or  puncture  should  be  made. 

The  venom  of  some  of  the  lizard  family,  as  the  Gila  monster  ^  {Ileloderma 
suspectum)  and  the  toad^  {Bnfo  vulgaris),  also  j)ossesses  toxic  properties.  The 
treatment  should  be  about  the  same  as  given  above  for  serpent  venom,  though  not 
quite  so  energetic. 

Venom  introduced  with  the  sting  of  the  scorpion  is  reported  as  causing  death 
in  the  Orient,  although  the  sting  of  the  variety  common  to  North  America  is  not 
dangerous. 

That  of  the  tarantula  is  occasionally  fatal,  a  case  having  been  reported  by  Dr. 
Thomas  A.  Pope,  of  Texas.  Death  was  caused  by  asphyxia,  due  to  closing  of  the 
larynx  and  trachea  from  swelling,  but  not  to  changes  in  the  blood. 

In  scorpion  and  tarantula  stings,  immediate  labial  suction  is  advised,  and  the 
local  application  or  injection  of  bicarbonate  of  potash  or  any  alkali. 

The  stings  of  bees^  wasps,  hornets,  etc.,  possess  a  venom  which,  while  rarely 
fatal,  is  painful.  The  prompt  application  of  an  alkaline  solution  will  neutralize 
the  poison  and  prevent  swelling.     If  the  sting  remains,  it  should  be  removed. 

The  venom  of  the  centipede  (Myriapoda)  produces  a  slight  irritation,  which 
may  be  neutralized  by  the  application  of  an  alkaline  solution. 

Gunshot  wounds,  in  general,  produce  contiisions  and  lacerations.  They  are  at 
times  complicated  by  fragments  of  cartridge,  clothing,  powder,  or  other  foreign 
matter  carried  in  with  the  projectile.  The  degree  of  laceration  is  usually  less  when 
the  ball  is  traveling  swiftly.  It  may  also  depend  upon  the  shape  of  the  missile. 
The  small-caliber,  long  projectile  used  in  modern  warfare  (Mauser,  Krag-Jorgen- 
sen,  etc.),  traversing  skin  and  muscle  "end  on,"  as  a  ride  does  little  damage.  The 
hole  of  entrance  is  small,  that  of  exit  larger.  Should  it  strike  a  bone,  it  may  pass 
through,  leaving  a  small-sized  hole  with  a  longitudinal  split.  If,  however,  it 
becomes  tilted  and  begins  to  turn  upon  its  axis,  it  is  apt  to  produce  extensive 
comminution  in  bone  and  widespread  laceration  and  destruction  of  the  soft  tissues.^' 

>  Mitchell  and  Reichert,  "Medical  News,"  Philadelphia,  1883. 

2  "Gazette  des  hopitaux,"  1881,  p.  598. 

3  During  the  Spanish-American  war,  a  number  of  these  wounds  came  under  the  author's 
observation.     In  one  instance  a  Mauser  missile  entered  the  pectoral  muscle  over  the  fifth  rib, 


ILEMORRHAGE,  AVOUNDS,  AND  WOUXD  SUTURE  47 

Wounds  of  the  liver,  spleen,  and  other  friable  organs,  caused  even  by  these 
smaller  missiles  traveling  at  great  speed,  are  characterized  by  widespread  destruc- 
tion, and  are  almost  of  necessity  fatal. 

In  civil  life,  injuries  received  from  a  shotgun  at  close  range  are  most  destructive, 
and  more  apt  to  be  immediately  fatal. 

Treatment. — Arrest  of  haemorrhage  is  the  first  indication.  In  military  service 
indelible  tracings  are  emplo3'ed  to  indicate  to  the  common  soldier  where  compression 
may  be  made  to  control  the  blood  supply.  Practical  instruction  is  given  in  the 
application  of  a  tourniquet  by  means  of  a  belt,  coat-sleeve,  bridle  rein,  etc.,  tied 
about  the  limb  and  twisted  by  bayonet,  sword,  or  stick.  Each  soldier  carries  a  well- 
protected  bit  of  sterile  gauze  to  apply  immediately  over  the  wound. 

Ha?morrhage  from  wounds  of  the  cavities  not  directly  accessible  may  in  a 
measure  be  controlled  bj'  Detmokrs  method  of  constriction  of  the  extremities.  (See 
Ha;morrliage. ) 

Immediate  operation  is  rarel}^  indicated  in  gunshot  wounds,  except  for  the 
arrest  of  hemorrhage  from  the  larger  vessels,  or  in  exceptional  instances  where 
there  is  serious  interference  with  respiration,  or  in  cases  of  perforation  of  tlie 
hollow  viscera.  Special  consideration  of  these  wounds  will  be  given  in  chapters 
which  treat  of  regional  surgery. 

made  its  exit  near  the  axilla,  reentered  the  muscular  substance  of  the  deltoid,  and  passed  out 
end-on,  doing  practically  no  harm,  the  holes  of  entrance  and  exit  being  very  small.  In  another 
instance  a  missile  which  tra^-eled  through  the  same  tissues,  on  the  opposite  side,  inflicted  very 
serious  results.  This  bullet  had  struck  an  obstacle  and  was  tumbling  on  its  long  ixis  when  it 
struck.  The  hole  of  entrance  was  over  an  inch  long  and  one  half  of  an  inch  in  width.  It  passed 
through  the  right  pectoral  muscle,  left  the  chest  wall  bj-  an  opening  about  half  the  size  of  that  of 
entrance,  entered  the  arm,  fractured  the  right  himierus.  turning  up  at  the  point  of  exit  a  U-shaped 
flap  of  integument.  In  another  Mauser  wound  the  ball  entered  just  above  the  left  ilium  near  the 
lumbar  vertebra,  passed  directly  through  the  abdomen,  and  made  its  exit  through  the  left  inguinal 
canal.  The  wounds  of  entrance  and  exit  were  small,  and  it  is  l^elieved  the  bowels  escaped  injury. 
The  patient  received  no  treatment,  and  made  a  prompt  recovery. 


CHAPTER   V 

AMPUTATIONS 

An  amputation  is  said  to  be  in  coniinmiy  when  the  bone  is  divided;  in  con- 
tiguity  wlien  the  member  is  removed  through  an  articulation. 

An  amputation  for  the  removal  of  parts  which  are  useless  or  deformed  is  one 
of  expediency;  under  more  urgent  conditions,  of  necessity.  Amputations  of  neces- 
sity are  subdivided  into  those  following  accident  and  those  from  disease. 

Amputations  after  accident  are  immediate,  primary,  and  secondary.  Immediate, 
when  done  during  shock,  usually  from  two  to  six  hours  after  the  injury;  primary, 
after  reaction  from  shock  and  before  the  symptoms. of  infection  are  present,  usually 
within  twenty-four  hours  of  the  injury ;  secondary,  when  performed  after  this  limit 
of  time,  and  during  the  prevalence  of  inflammation. 

The  prognosis  depends  upon  the  character  of  the  injury,  the  location  of  the 
line  of  section,  and  the  condition  of  the  patient  as  the  result  of  hsemorrhage,  shock, 
sepsis,  or  any  dyserasia  or  disease.  In  general,  the  gravity  is  proportionate  to  the 
diameter  of  the  part  divided  and  the  proximity  of  the  line  of  section  to  the  trunk. 

As  to  age,  the  death-rate  gradually  increases  with  each  decade. 

Iminediate  or  primary  operations  are  more  dangerous  than  the  secondary. 

In  determining  when  to  operate,  it  is  well  to  bear  in  mind  that  nervous  and 
fretful  patients,  chronic  alcoholics,  heavy  smokers,  those  suffering  with  kidney 
lesions  and  arterial  sclerosis,  the  very  old  and  the  very  young,  are  not  favorable 
subjects  for  conservatism. 

"  In  estimating  the  gravity  of  the  prognosis,  based  upon  laceration  of  the  soft 
tissues,  muscular  lacerations  should  receive  less  consideration  than  injury  to  the 
skin.  Limbs  with  extensive  laceration  of  muscle  and  comminution  of  bone  with 
slight  injury  to  the  skin  may  be  saved,  but  where  there  is  extensive  injury  to  the 
skin,  however  slight  the  laceration  of  muscle,  I  have  rarely  succeeded  in  saving  a 
compound  comminuted  fractured  extremity.  If  the  muscles  are  pulpified,  ampu- 
tation is  indicated.  Violent  injury  to  a  jjrincipal  set  of  vessels  does  not  always 
call  for  amputation,  especially  when  the  injury  is  fairly  well  removed  from  the 
shoulder-  and  the  hip- joint "  (W.  L.  Estes). 

The  thick  muscular  portion  of  the  extremities  will  resist  injury  better  than 
the  thinner  parts,  where  nerves,  vessels,  etc.,  are  nearer  the  skin  and  bone. 

In  the  forearm  and  leg,  if  only  a  single  artery  and  vein  is  severed  and  the  skin 
not  extensively  destroyed,  it  is  advisable  to  wait;  under  other  conditions,  amputa- 
tion should  be  done  at  the  earliest  possible  moment.  When,  after  a  crush,  more  or 
less  severe,  a  single  artery  and  vein  (brachial,  femoral)  is  severed,  delay  is  dan- 
gerous.    As  soon  as  reaction  is  well  established,  operation  is  advised. 

In  these  major  injuries  the  immediate  indication  is  the  arrest  of  haemorrhage 
by  elevating  the  bleeding  point  (posture),  by  direct  compression  of  the  lacerated 
tissues,  the  application  of  a  tourniquet,  the  thorough  cleansing  by  irrigation  with 
hot  salt  solution,  followed  with  a  1-3000  mercuric-chloride  (wet)  dressmg.  In  an 
emergency,  plain  hot  water  which  has  been  boiled  and  cooled  down  to  120°  F.  will 
suffice. 

In  applying  the  Esmarch  bandage  around  a  mangled  stump  or  over  the  crushed 
portion  of  a  limb,  it  should  be  placed  as  near  the  injury  as  possible,  and  once 
applied,  should  not  be  removed  until,  in  amputating,  the  soft  parts  have  been 
divided  on  its  proximal  side.    This  precaution  is  necessary  to  prevent  septic  organ- 

48 


AMPUTATIONS 


49 


isms  from  entering  the  lymphatics  and  veins.     If  necessary,  short  transfixion  pins 
may  be  employed  to  prevent  the  rubber  tourniquet  from  slipping  downward. 

When  extravasations  have  occurred  beneath  the  skin,  with  marked  swelling  and 
tension,  this  should  be  relieved  by  multiple  punctures,  covering  the  injured  area 
W'ith  a  wet  mercuric-chloride  dressing,  1-3000. 

SJiock. — After  an  injury  which  may  necessitate  an  amputation  a  condition  of 
collapse  often  ensues,  which  is  called  shock,  in  which  the  functions  of  the  nervous 
system  are  more  or  less  completely  suspended.  Shock  occurs  from  two  causes, 
licemorrliage  and  fright.  Psychical  shock,  though  comparatively  infrequent  and 
usually  of  short  duration,  is  occasionally  fatal.  Hcemorrhagic  shock  is  common,  is 
very  frequently  fatal,  may  last  for  hours,  and  in  rare  in- 
stances, after  an  interval  of  reaction,  may  recur.  In  psychi-  _^ns-:=ii=ff .^^^^'"''^'^  fi 
cal  shock,  general  anaesthesia  (ether)  is  not  contra-indicated,  |i|iiBipi  '] 

as  it  is  in  the  more  serious  exhaustion  following  hemorrhage.    l:;:i:i:-:i:|;-  I 

Nitrous  oxide  with  oxygen  or  air  should  be  preferred  when     T''  ' 

narcosis  is  necessary.  ^        _  ' 

When,  following  these  grave  injuries,  syncope  is  threat- 
ened, the  lower  extremities  should  be  elevated,  and,  if  neces- 
sary, an  Esmarch  bandage  applied  upon  the  iminjured  mem- 
bers, in  order  to  force  toward  the  heart  and  brain  all  the 
blood  in  the  extremities. 

To  bring  about  reaction  from  hcemorrhagic  shock,  an  im- 
mediate injection  into  a  vein  of  a  quantity  of  normal  salt 
solution  at  about  110°  F.  is  indicated  (Fig.  75).  From  eight 
ounces  to  two  or  three  pints  (or  more)  may  be  employed, 
the  quantity  required  being  determined  by  tlie  improvement 
in  the  character  of  the  pulse  and  the  general  symptoms  of 
reaction. 

A  vein  already  exposed,  or' one  of  the  superficial  veins  of 
the  arm,  may  be  used.  The  hypodermic  infiltration  of  a 
large  quantity  of  hot  salt  solution  over  the  chest  and  abdo- 
men maj''  also  be  considered.  Caffeine  and  camphor,  hypo- 
dermically,  are  among  the  most  reliable  stimulants.  One  or 
two  ounces  of  black  coffee  in  an  equal  quantity  of  whisky  may 
be  injected  per  rectum.  Normal"  salt  may  be  used  by  enema 
with  or  without  the  coffee  and  whisky  when  the  condition- of 
the  patient  is  not  extreme. 

The  prognosis  in  operations  of  expediency  is,  in  general, 
favorable,  since  the  line  of  section  is  made  through  uninfected 
tissues,  and,  as  a  rule,  the  general  condition  of  the  patient 
is  good.  When  infection  is  present,  as  in  osteomyelitis, 
tuberculosis,  etc.,  the  gravity  of  the  prognosis  is  increased. 
Amputations  on  account  of  malignant  neoplasms  are  more 
dangerous,  since  the  resistance  of  these  subjects  is  below  the 
normal. 

In  determining  the  point  at  which  an  amputation  should 
be  made  (with  only  few  exceptions,  which  will  be  noted  in 
treating  of  special  amputations)  the  general  rule  should  be 
to  save  as  much  of  the  length  of  limb  as  possible.  For  the 
upper  extremity  disarticulation  at  the  shoulder-joint  is  most 
fatal,  while  from  this  point  to  the  middle  of  the  forearm  the 
risk  is  about  the  same.  Amputations  through  the  knee  or 
through  the  tibia  within  three  or  four  inches  of  this  joint 
are  more  dangerous  than  those  between  this  point  and 
the  ankle.  From  the  knee-joint  upward,  the  danger  in- 
creases practically  for  every  inch  in  the  approach  to  the 
hip-joint. 

Operation. — An  amputation  may  be  made  entirely  blood- 
less by  using  the  elastic  bandage  (Fig.  76),  which  is  wound 


Fig.  76. — Esmarch 's  elas- 
tic bandage  and  tourni- 
quet.    (Esmarch.) 


50 


AMPUTATIONS 


tightly  around  the  limb  from  the  extremity  to  the  trunk.  While  in  position,  a 
rubber-tube  tourniquet  is  applied  at  the  upper  limit  of  the  Esmarch,  which  is 
then  removed. 

Since  haemorrhage  is  the  chief  cause  of  shock,  this  method  should  be  generally 
employed.  When  septic  infection  (phlebitis,  osteo-arthritis,  etc.)  is  present,  com- 
pression should  not  be  made  nearer  than  within  six  inches  of  the  infected  area, 
for  fear  of  forcing  pathogenic  organisms  into  the  circulation.  The  next  best 
method  is  to  hold  the  member  at  right  angles  to  the  body  for  five  or  ten  minutes 
before  the  tourniquet  is  applied  or  to  employ  the  full  Trendelenburg  posture. 

For  the  same  reason,  a  malignant  neoplasm  should  not  be  subjected  to  pressure 
in  applying  the  elastic  bandage.  It  is  well  to  note  that  capillary  oozing  is  more 
persistent  after  the  use  of  this  bandage. 

In  the  formation  of  faps,  whether  of  skin  alone  or  of  skin  and  muscle,  the 
first  essential  is  that  they  be  made  sufficiently  long.     Careful  measurements,  with 


a  fair  extra  allowance,  will  prevent  error.  In  general,  the  flap  composed  of  skin, 
with  just  enough  of  the  subcutaneous  fat  to  insure  its  vitality,  will  be  found  most 
satisfactory,  and  when  sufficiently  long  to  prevent  adhesions  to  the  end  of  the  bone, 
the  location  of  the  cicatrix  is  immaterial. 

The  combination  skin  and  muscular  flap  is  now  little  in  vogue.    In  amputations 
through  the  leg,  especially  in  diabetic  subjects  or  in  senile  gangrene,  it  may  be 


preferred.    The  circular  (Tig.  77)  or  modified  circular  (Fig.  78)  method  will  fill 
almost  every  requirement. 

In  thin  subjects  the  circular  incision  should  extend  down  to  the  deep  fascia, 
from  which  it  is  separated  by  careful  dissection  with  the  scalpel  or  the  bliint- 
pointed  scissors.  A  longitudinal  slit  for  a  sufficient  distance,  as  shown  in  Fig.  78, ' 
facilitates  the  dissection,  minimizes  traumatism,  and,  moreover,  serves  as  an  exit 
for  drainage.  One  half  of  an  inch  in  front  of  the  point  at  which  the  bone  is  to 
be  divided,  with  the  flap  held  out  of  the  way,  all  the  soft  tissues  should  be  squarely 
divided  down  to  the  bone,  and,  without  disturbing  the  periosteum,  the  muscles 
lifted  from  the  bone  by  dry  dissection  for  another  half  inch,  so  that  the  latter 


AMPUTATIONS  51 

may  be  sawed  this  much  nearer  the  body  than  the  line  of  section  through  the  soft 
parts.  A  gauze  mat,  or  sterUe  towel  split  half-way,  should  now  be  laid  over  the 
end  of  the  stump,  to  serve  as  a  retractor  as  the  saw  is  being  used.  In  applyiug 
this  instrument  it  should  be  placed  against  the  bone  close  to  the  retractor,  taking 
care  to  hold  its  blade  in  such  relation  to  the  shaft  that  the  sawn  surface  will  be  at 
right  angles  to  the  axis  of  the  bone.  A  few  short,  light  strokes  will  suffice  to  cut 
a  trench  or  hold  for  the  saw,  which  may  tlien  be  more  rapidlj'  used.  The  operator 
steadies  the  stump  with  his  left  hand,  while  an  assistant  holds  the  extremit}^  When 
the  section  is  about  complete,  the  strokes  of  the  saw  should  be  very  light,  in  order 
to  avoid  splintering.  jSTo  periosteal  cufE  should  be  used.  With  a  bone  cutter  or 
cartilage  knife  the  sharp  edge  of  the  cut  surface  is  smoothed  and  rounded  off.  In 
doing  this,  the  force  applied  should  always  be  toward  the  center  of  the  bone,  to 
prevent  stripping  the  periosteum  or  splintering. 

The  end  of  the  bone  should  be  flushed  with  salt  solution,  the  retractor  removed, 
the  entire  stump  irrigated  with  the  saline  soliition  and  thoroughly  dried.  The 
larger  arteries  and  veins  may  be  readily  found,  and  their  ends  seized  with  the 
forceps  and  drawn  slightly  out,  any  contiguous  nerves  excluded  by  blunt  dissection 
(grooved  director),  and  plain  catgut  ligatures  applied.^  Minor  bleeding  points 
may  be  discovered  by  grasping  the  limb  a  few  inches  above  the  line  of  section  and 
milking  out  the  small  quantity  of  blood  which  has  remained  in  the  vessels. 

The  entire  wound  should  now  be  filled  with  dry  sterile  gauze,  covered  with 
towels,  and  firmly  compressed,  while  the  assistant  entirely  loosens,  hut  does  not 
wholly  remove  the  tourniquet.  After  waiting  two  or  three  minutes  for  the  vessels  to 
fill,  the  packing  is  carefully  removed,  and  any  bleeding  points  immediately  caught 
with  the  forceps.  Should  an  unexpected  htemorrhage  occur,  the  tourniquet  is  at 
once  tightened. 

It  is  essential  that  all  bleeding  or  oozing  be  stopped  before  the  wound  is  closed. 

Under  certain  conditions,  especially  where  the  muscular  surfaces  are  extensive 
and  oozing  is  free,  time  may  be  saved  by  passing  catgut  sutures  attached  to  long 
straight  Hagedorn  needles  through  several  inches  of  the  ends  of  the  divided  mus- 
cles, tying  these  just  tight  enough  to  arrest  the  bleeding. 

In  sewing  up  the  cuff,  alternate  deep  and  superficial  silkworm-gut  sutures — 
inserted  one  eighth  and  one  fourth  of  an  inch  respectively  from  the  edge  of  the 
flajj — are  preferable.  The  edges  should  be  accurately  in  apiposition.  Just  before 
the  final  dressing  is  applied  the  limb  should  be  elevated  in  the  position  in  which 
it  will  rest  in  bed,  and  a  catgut  bundle  drain  -  brought  out  at  the  upper  angle  of 
the  longitudinal  incision   (in  this  position  the  lowest  point). 

In  applying  the  dressing  no  pressure  should  be  made  against  the  end  of  the 
bone.  The  bandage  should  be  just  tight  enough  to  control  oozing  and  quiet  mus- 
cular quivering  without  interfering  with  the  vitality  of  the  flaps.  A  light  board 
splint  is  usually  needed,  and  a  wire  arch  to  hold  the  bedclothes  from  contact.  The 
dressing  need  not  be  changed  for  eight  or  ten  days  unless  for  pain,  hfemorrhage, 
temperature,  or  odor.     The  sutures  may  be  removed  about  the  tenth  day. 

When  an  amputation  is  made  through  infected  tissues,  it  is  often  advisable  to 
treat  the  stump  by  the  open  method  either  with  moist  1-3000  mercuric-chloride 
gauze,  frequently  changed,  or  a  more  or  less  continuous  irrigation  with  warm  nor- 
mal salt  solution. 

Special  Amputations 

Hand  and  Fingers. — A  primary  amputation  of  any  portion  of  the  hand  is  rarely 
justifiable.  If  there  is  only  a  small  strip  of  tissue,  the  integrity  of  which  is  evident, 
an  effort  at  the  restoration  of  the  nutrition  and  function  of  the  part  beyond  should 
be  attempted.     If  any  doubt  exists  as  to  the  result,  the  benefit  of  this  should  be 

1  Nothing  but  plain  catgut,  No.  2  for  the  larger  vessels.  Single  knot  a  fourth  of  an  inch  from 
the  end  so  snugly  drawn  that  it  cannot  slip,  the  first  loop  not  permitted  to  loosen,  while  the  second 
is  being  run  down.  Always  a  third  knot  with  all  animal  ligatures  or  sutures.  When  haste  is 
indicated,  an  artery  and  vein  may  be  included  in  the  same  ligature.  When  the  arteries  are  ather- 
omatous and  brittle,  include  a  protecting  sheath  of  connective  tissue  in  the  ligature. 

^  Ten  to  twenty  strands  of  No.  2  chromicized  catgut  arranged  parallel,  not  twisted. 


52 


AMPUTATIONS 


given  to  the  side  of  conservatism.  It  is  essential  to  arrest  haemorrhage,  cleanse 
the  wounds  under  strict  antisepsis,  and  especially  by  thorough  immersion  in  a 
basin  of  warm  sublimate  solution  (1-3000),  secure  drainage,  and  place  the  parts 
in  the  best  position  for' usefulness  in  case  of  recovery.  Amputation  may  be  clone 
when  necessitated  by  gangrene  or  necrosis. 

Fingers — Inter  phalangeal  Operations. — Between  the  second  and  third  phalanges 
of  the  fingers,  proceed  as  follows :  Flex  the  terminal  phahmx  at  about  an  angle 
of  ninet}'  degrees  to  the  axis  of  the  second  bone,  and  one  eighth  of  an  inch  anterior 
to  the  angle  on  the  dorsal  aspect,  with  a  small,  sharp-pointed  scalpel  make  a  trans- 
verse incision,  extending  half-way  do-svn  the  sides  of  the  finger.  From  this  point 
carry  the  incision  forward,  parallel  with  the  axis  of  the  digit,  to  within  a  quarter 
of  an  inch  of  the  end,  then  across  the  palmar  aspect  of  the  tip  to  the  opposite 
side,  finishing  the  incision  at  the  angle  of  the  transverse  cut  (Fig.  79).  Dissect 
the  palmar  flap  up,  keeping  close  to  the  bone,  lifting  the  flexor  tendon  with  the 
skin  back  to  the  articulaition ;  divide  the  tendon  opposite  the  joint,  and  disarticulate. 
The  flap  is  now  turned  back,  trimmed  with  the  scissors  to  fit  nicely,  and  sutured 
with  fine  linen.  By  this  method  the  acute  tactile  sense  of  the  palmar  aspect  of 
the  finger  is  preserved.  This,  and  other  amputations  of  the  fingers,  may  be  made 
without  general  anaesthesia,  and  with  perfect  insensibility,  by  the  local  use  of 
cocaine.  Just  anterior  to  the  metacarpo-phalangeal  joint  insert  on  each  lateral 
aspect  of  the  finger  the  needle  of  a  hypodermic  syringe,  and  inject  in  the  entire 
■circumference  of  the  finger  30  to  50  minims  of  a  one-per-cent  solution  of  cocaine 
hydroehlorate.  As  soon  as  the  anaesthesia  is  complete  the  rubber  tubing  should  be 
applied  to  control  bleeding. 

If  a  considerable  quantity  of  cocaine  has  been  required,  it  is  advisable  to  loosen 
the  elastic  ligature  for  oply  a  few  seconds  and  then  tighten  it,  and  to  repeat  this 
procedure  several  times  in  the  space  of  above  five  minutes,  so  that  the  cocaine  in 
the  tissues  will  be  gbadually  liberated  and  carried  into  the  circulation. 

In  dressing  these  amputations  the  pressure  on  the  end  of  the  stump  should  be 
light,  for  fear  of  slougli  in  the  long  flap.  Usually  no  vessels  need  to  be  tied.  The 
covering  of  cartilage  does  not  require  to  be  removed.  When  only  a  slight  portion 
of  the  anterior  tip  of  the  second  phalanx  is  involved,  the  remaining  portion  should 
not  be  sacrificed  by  a  disarticulation.  The  line  of  section  through  the  bone  should 
be  about  at  the  junction  of  the  middle  and  anterior  third  of  the  phalanx.  The 
incisions  and  flap  are  made  as  in  the  preceding  operation. 

In  amputation  with  disarticulation  at  tlie  posterior  interphalangeal  joint,  flex 
at  an  angle  of  ninety  degrees,  make  a  transverse  incision  over  the  dorsum  of  the 
finger,  from  one  eighth  to  one  fourth  of 
an  inch  in  front  of  the  angle,  which  in- 
cludes half  the  circumference  of  the  mem- 
ber. From  the  ends  of  this  line  carry  the 
incision  directly  forward  on  each  lateral 
aspect  of  the  finger  to  the  crease  on  the 
palmar  surface  opposite  the  anterior  in- 
terphalangeal joint.  A  second  transverse 
incision  in  this  fold  completes  the  rectan- 
gular flap,  which  is  now  dissected  back. 


and   the    disarticulation    effected   by   placing   the   ligaments    on    the   stretch    and 
dividing   these   with    a    narrow,    sharp    scalpel.      If    any    difficulty    is    found    in 


A-MPUTATIOXS 


53 


entering  the  joint  from  the  sides  or  front,  it  may  be  easily  done  by  division  of 
the  extensor  tendons  over  the  dorsum,  for  these  take  the  place  of  posterior  liga- 
ments. The  method  of  amputation,  as  given  for  the  operation  at  or  near  the 
articulation  of  the  first  and  second  phalanges  of  the  finger,  applies  also  to  the  thumb 
in  amputation  at  the  last  joint,  or  through  the  first  phalanx,  -nithia  one  fourth 
of  an  inch  of  its  anterior  extremity". 

At  the  Metacarpo-phalangeal  Joint — Thumb. — When  the  condition  of  the  soft 
parts  Tvill  permit,  proceed  as  f oIIotvs  : 

First  Method. — Just  over  the  joint,  and  in  the  middle  of  the  dorsal  aspect  of 
the  thtunb,  commence  an  incision  and  carry  it  along  the  surface  next  to  the  index- 


FiG.  S3.— (After  Esmarch.) 


finger  until  half  the  circumference  of  the  member  is  included.  Along  the  dorsal 
and  palmar  aspects  carry  parallel  incisions  forward  until  near  the  interphalangeal 
joint,  and  connect  these  by  a  straight  transverse  cut  across  the  palmar  surface. 
Dissect  the  flap  back,  divide  all  tendons  opposite  the  joint,  disarticulate,  tie  the 
dorsales  poUicis  (one  on  either  side  of  the  back  of  the  thumb),  and  the  arteria 
princeps  poUicis,  which  lies  along  the  side  of  the  metacarpal  bone  nearest  the  index- 
finger  and  divides  into  its  terminal  branches  opposite  the  metacarpo-phalangeal 
joint.  When  the  flap  is  stitched,  the  scar  will  be  in  good  part  concealed  on  the 
ulnar  aspect  of  the  stump. 

Second  2Iethod. — A  transverse  dorsal  incision  is  made  over  the  articulation, 
extending  half  aroimd  and  ending  at  opposite  points  on  the  external  and  internal 
lateral  aspects  of  the  thumb.  Parallel  lateral  incisions  are  made  as  far  forward 
as  the  interphalangeal  joint,  and  the  anterior  extremities  of  these  are  joined  by  a 
transverse  palmar  cut  (Fig.  80).  The  end  of  the  metacarpal  bone  of  the  thumb 
should  be  left  undisturbed,  when  not  necrosed  and  when  there  is  sound  skin  enough 
to  cover  it.  L'nder  other  conditions  it  may  be  divided  with  a  fine  saw.  It  is 
especially  important  to  a  laborer  that  the  end  of  the  metacarpal  bone  be  preserved 
(Fig.  81).  For  one  not  compelled  to  do  manual  work,  a  more  symmetrical  appear- 
ance may  be  obtained  by  an  oblique  section  of  the  metacarpal  bone  about  half 
an  inch  behind  the  articular  surface.  The  incision  through  the  skin  should  be 
such  that  the  long  part  of  the  flap  is  obtained  from  the  radial  and  palmar  aspect 
of  the  thumb,  while  the  line  of  sutures  is  situated  well  on  the  dorsal  surface  of  the 
stump  (Fig.  83). 

Index-Finger — At  the  Metacarpo-phalangeal  -Joint — First  Method. — Wlien  pos- 
sible, the  following  method  should  l^e  adopted,  the  object  being  to  preserve  the 
tactile  sense  and  to  leave  the  scar  less  prominent: 

From  the  ulnar  side  of  the  knuckle,  and  just  over  the  joiat,  make  an  incision 
which  extends  from  this  point  forward  as  far  as  the  web  between  the  index-  and 
middle  finger,  and,  in  case  of  a  large  knuckle,  a  little  beyond  this  point  at  the 


54 


AilPUTATIONS 


side  of  the  digit.  From  the  anterior  end  of  this  incision  make  a  second  cut  directly 
across  tlae  palmar  aspect  of  the  phalanx  imtil  the  middle  of  the  radial  side  of  the 
finger  is  reached,  and  complete  the  iiap  by  cutting  in  a  straight  line  from  this 
point  to  the  commencement  of  the  first  incision.  AVhen  the  disarticulation  is 
completed,  the  dorsalis  and  radialis  indicis  arteries,  and  the  external  digital 
branches,  tied  with  fine  catgut,  the  corner  of  the  flap  is  carried  into  the  receding 
angle  on  the  dorsal  surface  of  the  metacarpal  bone  and  secured  by  sutures.  When 
the  head  of  the  metacarpus  is  to  be  removed,  the  section  of  this  bone  should  be 
slightly  oblique,  and  the  line  of  incision  a  partial  oval,  beginning  at  the  web 
between  the  two  fingers,  and  traveling  along  the  crease  formed  by  flexion  of  the 
finger  on  the  metacarpus  well  up  on  the  dorsum  of  this  bone,  about  three  fourths 
of  an  inch  back  of  the  joint.  An  incision,  almost  in  a  straight  line,  should  now 
be  made  between  the  ends  of  this  curved  line  (Fig.  80).  Dissect  the  fiaps  clear 
and  without  making  a  disarticulation,  expose  the  bone,  and  with  a  fiiie  saw  divide 
it  obliquely  from  before  backward,  and  from  the  ulnar  toward  the  radial  aspect. 
In  amputation  of  the  middle  or  the  ring-finger,  the  following  method  should  be 
preferred : 

Middle  Finger. — Locate  the  articulation  exactly,  and  over  this  point  make  a 
transverse  incision  extending  on  either  side  to  tlie  middle  of  the  depression  between 
this  digit  and  the  index-  and  ring-fingers  (Fig.  80).  From  either  end  of  this  cut 
carry  a  lateral  incision  directly  forward  about  half-wa}^  up  the  first  phalanx,  and 
connect  these  by  a  transverse  incision  across  the  palmar  aspect  of  the  digit  (Fig. 
81).  Disarticulate  and  fold  the  palmar  end  of  the  flap  back  upon  the  dorsal 
transverse  incision  where  it  is  stitched. 

Another  method  is  the  oval  incision,  shown  in  Fig.  8-3.  By  the  first  method  the 
tactile  surface  is  better  .preserved.  The  head  of  the  metacarpal  bone  should  be 
left  intact  for  laborers.     AVhen  the  round  expansion  of  this  bone  is  removed,  the 


gap  between  the  index-  and  ring-fingers  is  not  so  wide.  The  bone  should  be  sawed 
squarely  across  a  half  inch  behind  the  articular  surface.  All  that  has  been  said 
of  this  digit  applies  with  equal  force  to  the  ring-finger. 

Little  Finger.- — The  method  recommended  in  amputation  of  the  index  at  the 
metacarpal  joint  should  be  preferred  in  removing  the  little  finger  at  the  same 
level.  The  flap  should  be  so  shaped  that  the  cicatrix  will  fall  on  the  dorsum  and 
toward  the  ring-finger.  When  the  metacarpal  bone  is  to  be  divided  it  should  be 
cut  with  a  slight  oljliquity.  In  this  operation  the  oval  incision  shown  in  Fig.  84 
should  be  made. 

When  two  or  more  fingers  require  to  be  removed  at  the  metaearpo-phalangeal 
joint,  each  one  may  he  amputated  by  tlie  methods  described  as  especially  suited  to 
it,  or  a  common  antero-posterior  flap  may  be  made.    As  to  the  propriety  of  removing 


A-AIPLTATIOXS 


55 


the  ends  of  the  metacarpal  bones,  the  same  rules  apply  as  already  given  for  the 
single  amputations. 

Through  the  Metacarpus. — When  the  end  of  the  metacarpus  cannot  he  saved, 
these  bones  should  Idc  divided  at  any  point  three  fourths  of  an  inch  or  more  anterior 
to  the  carpo-metacarpal  articulation.  If  the  injury  extends  behind  this  line,  it  is 
better  to  disarticiilate  at  the  carpo-metacarpal  junction.  In  amputation  through 
the  metacarpus,  the  flap  should  be  made  chiefly  from  the  palmar  tissues,  so  that  the 
liae  of  sutures  and  the  scar  will  be  well  on  the  dorsum  of  the  hand,  and  as  much 
of  the  tactile  sense  preserved  as  possible. 

Carpo-metacarpal  DisartkuJation. — Wlien  all  the  bones  of  the  metacarpus  re- 
quire to  be  removed,  on  accoimt  of  a  lesion  not  involving  the  anterior  row  of  the 


carpus,  the  amputation  should  be  made  through  the  metacarpo-carpal  line.  If  the 
anterior  row  is  involved,  the  entire  carpus  should  be  removed.  When  the  thumb 
is  intact,  and  the  metacarpal  bones  of  the  foiir  fingers  require  removal,  the  incision 
as  given  by  Esmarch  should  be  followed.  A  curved  incision  is  made  across  the 
palm,  beginning  at  the  middle  of  the  web  between  the  thumb  and  index-finger,  and 
carried  outward  to  the  ulnar  side  of  the  base  of  the  fifth  metacarpal  bone  (Fig.  85). 
The  dorsal  incision  commences  at  the  web  between  the  thumb  and  finger,  and  is 
carried  obliquely  upward  toward  the  carpus  until  the  junction  of  the  middle  and 
upper  third  of  the  metacarpal  bone  of  the  index-finger  is  reached,  whence  it  travels 
across  the  back  of  the  hand  to  join  the  end  of  the  palmar  incision  (Figs.  86,  87). 

Amputation  of  the  thumb  with  disarticulation  at  the  carpo-metacarpal  junction 
should  be  done  as  follows :  Just  over  the  carpo-metacarpal  joint  on  the  dorsal  aspect 
of  the  hand  commence  an  incision,  and  carry  it  directly  along  the  metacarpal  bone 
until  half-way  to  the  metacarpo-phalangeal  articulation,  from  which  point  it  is 
made  to  travel  along  the  groove  between  the  thumb  and  index-finger  to  the  middle 
of  the  web  between  these  two  members,  thence  on  around  the  base  of  the  thiimb 
until  the  dorsal  incision  is  reached  (Fig.  88).  In  amputation  of  the  little  finger, 
at  the  carpo-metacarpal  joint,  a  similar  incision  is  made  (Fig.  89). 

The  character  of  the  injury,  the  general  condition  of  the  individual,  the  vitality 
of  the  parts  involved,  may  necessitate  various  modifications  of  the  foregoing 
methods.  In  the  surgery  of  the  hand,  the  rule  in  practice  should  lie  never  to 
amputate  when  possible  to  avoid  it,  and  never  to  remove  any  more  than  is  aiso- 
lutely  necessary.  Fig.  90  is  that  of  an  amputation  after  an  injury  from  the  explo- 
sion of  a  shotgun,  in  which  the  tlranib,  index-  and  middle  fingers,  and  their  respect- 
ive metacarpal  bones,  were  blown  off.  The  line  of  incision  was  a  lateral  one,  and 
the  disarticulation  was  at  the  carpo-metacarpal  joint. 

Radio-carpal  Joint. — In  amputation  at  the  wrist  the  carpus  should  be  removed, 
€ven  when  all  the  bones  of  this  group  are  not  involved.     The  line  of  incision  will 


56 


AiAIPUTATIONS 


depend  upon  the  extent  of  the  healthy  tissues  available  for  forming  the  covering 
to  the  stump.  The  long  palmar  and  short  dorsal  flaps  are  preferable  on  account  of 
the  finer  tactile  sense  of  the  covering  thus  secured.  Moreover,  the  vitality  of  the 
palm  is  so  great  that,  if  ordinary  precautions  are  observed  in  its  dissection,  slough- 
ing will  not  occur. 

First  Method. — Place  the  thuml}  and  finger  of  the  left  hand  respectively  upon 
the  styloid  of  the  radius  and  ulna,  and  make  an  incision  across  the  dorsal  surface 
of  the  wrist  which  shall  divide  everything  straight  down  to  the  bones  and  into  the 
cavity  of  the  joint.  This  incision  reaches  half-way  down  the  lateral  aspects  of 
the  wrist.  At  the  radial  end  of  this  cut  enter  the  scalpel,  and,  in  shaping  the 
long  flap,  follow  the  center  of  the  dorsum  of  the  metacarpal  bone  of  the  thumb 
as  far  as  the  metacarpo-phalangeal  articulation.  From  this  point  cut  directly 
across  iln   |'  i':  i  i"  the  ulnar  side  of  the  fifth  metacarpal  bone,  and  back  along  this 


i-  - 
^  - 


.4 


to  join  the  dorsal  incision.  Dissect  the  flap  closely  from,  the  flexor  tendons,  andl 
divide  all  tendons  opposite  the  wrist-joint.  Apply  a  cloth'  retractor,  and'  saw 
through  the  styloid  of  the  radius  and  idna  just  at  the  level  of  the  articular  surface- 
of  the  radius,  but  not  necessarily  taking  a  section  from  this  surface.  The  radial, 
ulnar,,  anterior,  and  posterior  carpal  vessels  are  tied,  the  palmar  flap  is  trimmed 
down  to  fit  snugly,  and  stitched  in  proper  position.  The  catgut  drainage  comes  out 
on  either  side  (Fig.  91). 

Second  Method. — if  the  condition  of  the  soft  tissues  is  such  that  the  long 
palmar  flap  cannot  be  obtained,  the  circular  method  may  be  practiced.  It  is  always 
advisal)le  to  make  a  longitudinal  split  in  the  cufE  along  its  ulnar  aspect,  from  the- 
angle  of  which  the  drain  is  brought  out.  Under  other  conditions,  a  lateral  flap 
may  be  utilized,  after  the  third  method  (Figs.  92,  93),  in  the  flap  from  the  thumb 
side;  or  the  fourth  method  in  which  the  flap  is  taken  from  the  ulnar  aspect  of 
the  hand. 


AJVIPUTATIONS 


57 


Forearm  above  the  Wrist. — In  ampiitations  through  the  forearm,  the  circular 
or  modified  circular  skin-flaps  are  preferable. 

The  anatomical  relations  are  shown  in  Figs.  9-1,  95,  96,  and  97,  which,  with 
only  slight  modifications,  I  have  copied  from  Prof.  Braune's  magnificent  work. 


Fig.  94.' — ^Transverse  section  through  the  right  upper  extremitj',  one  fourth  of  an  incli  anterior  to  the 
plane  of  the  radio-carpal  articulation.  Looking  at  the  surface  of  the  stump.  1,  Radial  artery  and 
veins.  2,  Ulnar  artery,  veins,  and  nerve.  3,  Tendons  of  deep  and  superficial  flexors.  4,  Tendon 
of  extensor  ossis  metacarpi  and  primi  internodii  pollicis.  5,  Flexor  carpi  radialis.  6,  Palniaris 
longus.  7,  Fibers  of  the  flexor  brevis  minimi  digiti,  from  the  annular  ligament.  8,  Flexor  carpi 
ulnaris.  9,  10,  Extensor  carpi  radialis  longior  et  brevior,  and  tendon  of  secundi  internodii 
pollicis.  li.  Extensor  communis  digitorum.  12,  Extensor  minimi  digiti.  13,  Extensor  carpi  ra- 
dialis.    Superficial  veins  and  nerves  are  seen  in  the  subcutaneous  tissues. 


When  the  line  of  amputation  is  so  close  to  the  elbow-joint  that  division  of  the 
bones  is  necessitated  within  an  inch  of  the  articular  surface  of  the  head  of  the  radius, 
the  operation  to  be  preferred  is  a  disarticulation  at  the  elbow,  with  removal  of  the 
olecranon.  When  the  bones  can  be  preserved  at-  the  level  of  the  lower  border  of 
the  bicipital  tuberosity  of  the  radius,  the  joint  should  not  be  invaded. 


Fig.  95. — Transverse  section  showing  the  relations  of  the  tissues  divided  in  amputation  through  the 
lower  third  of  the  right  forearm.  Looking  from  below  upward.  1,  Radial  artery  and  veins.  .Just 
below  this,  tendon  of  supinator  longus,  radial  nerve,  and  close  to  the  radius  the  tendons  of  the 
extensor  ossis  metacarpi  pollicis  and  extensor  carpi  radialis  longior  and  brevior.  2,  Llnar  artery, 
veins,  and  nerve.     3,  Median  nerve.     4,  5,  The  post'^rior  and  anterior  interosseous  arteries. 


Amputation  at  this  level  (Fig.  97)  should  be  made  subject  to  the  rules  just 
given  for  other  portions  of  the  forearm  between  the  wrist  and  the  insertion  of  the 
biceps  humeri. 

'  All  of  these  cuts  represent  the  surface  nearest  tne  patient's  body,  i.e.,  the  surface  on  which 
the  vessels  are  searched  after  an  amputation. 


58 


AMPUTATIONS 


At  the  Elbow-joint — First  Method. — Make  a  circular  incision  through  the  skin 
from  one  inch  to  one  inch  and  a  half  below  the  level  of  the  internal  condyle.    Along 


Fig.  96. — Transverse  section  through  the  middle  of  tlie  riglit  forearm.  Looking  from  the  periphery 
toward  the  center.  Sliowing  tlie  relations  of  the  tissues  divided  in  amputation  at  this  point.  1, 
Radial  artery,  veins,  and  nerve.     2,  Ulnar  ditto.    3,  Median  nerve.     4   Anterior  interosseous  vessels. 


.  97. — Transverse  section  tlirough  the  upper  third  of  the  right  forearm.  Looking  from  the  periphery 
toward  the  center.  1,  Radial  artery,  muscular  branches,  veins,  and  radial  nerve.  2,  Ulnar  and 
interosseous  arteries,  veins,  and  median  nerve.  3,  Ulnar  nerve.  The  tendon  of  insertion  of  the 
biceps  is  seen  witii  the  radius. 


AilPUTATIONS 


59 


the  posterior  aspect  of  the  ulna  make  a  second  incision,  splitting  the  sleeve  of  skin 
as  far  back  as  the  end  of  the  olecranon.  Dissect  up  the  flap  from  the  muscles  and 
deep  fascial  attachment  until  the  joint  is  exposed  in  front,  and  the  olecranon  pos- 
teriorly. Extend  the  forearm  full}',  enter  the  articulation  between  the  head  of  the 
radius  and  the  humerus,  disarticulate,  and  saw  off  the  articular  surface  at  the  level 
of  the  lower  portion  of  the  internal  condyle.  The  draiilage  is  from  the  highest 
point  in  the  perpendicular  incision. 

Second  Method. — Make  a  circular  incision  down  to  the  deep  fascia  from  one 
to  two  inches  anterior  to  the  tip  of  the  internal  condyle  of  the  humerus,  and,  when 
the  skin  has  retracted,  at  the  level  of  the  line  of  retraction  divide  all  the  tissues 
to  the  bones.  Along  the  posterior  surface  of  the  ulna  make  an  incision  extending 
as  high  as  the  olecranon  process.  Dissect  tlie  soft  tissues  neatly  from  the  periosteum 
and  capsule  back  to  the  condyles  on  the  lateral  and  anterior  aspects  of  the  humerus, 


Fig.  98. — Transverse  section  of  right  arm  just  below  tlie  elbow-joint.  Looking  at  the  surface  nearest  the 
body.  1,  Brachial  arter3^  at  the  point  of  division  into  ulnar  and  radial.  2,  Median  basilic  vein  com- 
municating with  brachial.  3,  The  radial  and  interosseous  di^^sions  of  the  musculo-spiral  nerve  and 
radial  recurrent  arterj-.  4,  Tendon  of  biceps.  5,  Median  nerve  and  anterior  ulnar  recurrent  artery. 
6,  Ulnar  nerve  and  posterior  ulnar  recurrent  arterj'. 


and  along  the  olecranon  somewhat  higher,  in  order  to  facilitate  disarticulation  and 
the  complete  removal  of  the  synovial  bursa,  beneath  tlie  insertion  of  the  triceps. 
When  the  disarticulation  is  completed,  apply  a  cloth  retractor  and  saw  a  portion 
of  the  articular  surface  oil  at  the  same  level  as  given  in  the  preceding  operation. 
The  flaps  are  now  sutured,  leaving  the  drainage  at  the  upper  limit  of  the  incision, 
over  the  olecranon. 

Fig.  98  shows  the  anatomical  relations  near  the  line  of  section  of  the  soft  parts 
involved  in  this  amputation. 

Arm  below  the  Shoulder-joint. — The  circular  skin-flap  is  always  jJi'eferable. 

First  Method. — ]\lake  a  circular  cut  do\ra  to  the  muscles,  and  a  longitudinal 
incision  to  the  same  depth  along  the  outer  side  of  the  arm.  Dissect  the  sleeve  of 
skin  carefully  up  to  the  line  of  section  of  the  humerus,-  and  at  this  point  divide 
the  muscles  and  bone. 

The  anatomical  relations  in  the  several  regions  of  the  arm  are  shown  in  Figs. 
99,  100,  and  101. 


60 


AMPUTATIONS 


When  the  line  of  amputation  is  so  near  the  shonlder-joint  that  section  of  the 
bone  is  required  at  the  anatomical  neck,  the  head  of  the  humerus  should  be  dis- 
articulated. 


Fig.  99. — Section  through  the  condyloid  expansion  of  th(  right  irni  Looking  at  the  surface  nearest  the 
body.  1,  Brachial  artery  and  veins,  and  the  median  basiUc  vein.  2,  Musculo-splral  nerve  and. 
superior  profunda  artery  about  the  point  of  anastomosis  with  the  radial  recurrent.  3,  Median  nerve. 
4,  Biceps  tendon.     5,  Ulnar  nerve.     6,  Triceps  tendon. 


Fig.  100. — Transverse  section  through  junction  of  middle  and  lower  thirds  of  right  arm.  Looking  from 
belo\y  upward.  1,  Bracliial  artery,  vein,  median  nerve,  and  basilic  vein.  Near  by  the  ulnar  nerve 
and  inferior  profunda  artery.  2,  Musculo-spiral  nerve,  superior  profunda  artery,  and  supinator 
longus  muscle.     Cephalic  vein  to  outer  side  of  the  biceps  muscle. 


AMPUTATIONS 


61 


Second  Method — Circular  Shin  and  Muscle  Flap. — Make  a  circular  cut  through 
the  skin  at  a  point  sufficiently  below  the  line  of  section  through  the  humerus  to 
permit  a  suitable  covering.  Allow  the  skin  to  retract  up  the  arm,  and  at  this 
point  divide  everything  smoothly  and  squarely  down  to  the  bone.  Eender  the  skin 
and  muscles  tense,  push  the  point  of  the  scalpel  do^vn  to  the  bone  on  the  outer  side 
of  the  arm,  and  lay  the  flap  open  by  an  incision  which  is  parallel  with  the  axis 
of  the  humerus.  Dissect  the  tissues  closely  from  the  periosteum  up  to  the  point 
where  the  saw  is  to  be  applied,  and,  after  protecting  the  soft  parts  with  a  retractor, 
divide  the  bone.     The  drainage  should  be  from  the  upper  extremity  of  the  per- 


PiG.  101. — Transverse  section  showing  the  relations  of  parts  divided  in  amputation  just  above  the  middle 
of  tlie  hunierus.  Right  side.  Loolcing  toward  tlie  center.  1,  Bracliial  artery.  Near  this  the 
median  nerve  and  brachial  veins.  Internal  to  it  the  ulnar  ner\-e  and  inferior  profunda  artery. 
More  superficial,  the  basilic  vein.  2,  Musculo-spiral  nerve  and  superior  profunda  artery.  3,  Nu- 
trient artery  in  the  substance  of  the  coraco-brachialis  muscle.     4,  Cephalic  vein. 

^Dendicular  cut,  which,  with  the  stump  properly  elevated,  will  be  the  most  dependent 
portion  of  the  wound. 

Amputations  through  the  humerus,  especially  in  young  and  growing  bones,  not 
infrequently  fail  of  success  by  reason  of  so-called  conical  stump — a  projection  of 
hone  through  the  tissues  of  the  flap.  This  condition  supervenes  in  a  proportion 
of  cases  sufficient  to  justify  the  surgeon  in  stating  at  the  time  of  such  an  operation 
that  a  conical  stump  may  result  even  with  very  long  flaps. 


Amputation  at  the  Shoulder-joint — The  Author's  Method 

In  1888,  at  the  New  York  Polyclinic  Medical  School  and  Hospital,  I  removed 
the  outer  portion  of  the  clavicle,  the  glenoid,  acromion  and  coracoid  processes,  and 
a  small  portion  of  the  body  of  the  scapula,  together  with  the  upper  extremity  of  a 
patient  suffering  from  a  large  sarcoma  of  the  upper  articular  end  of  the  humerus 
hy  the  following  original  method :  With  a  stout  mattress  needle  I  transfixed  the 
skin  and  a  portion  of  the  pectoralis  major  muscle  about  three  inches  from  the  shoul- 


62 


AMPUTATIONS 


der,  and  at  about  the  same  distance  from  the  joint  on  the  dorsum  scapula  I 
introduced  a  second  needle  in  such  a  way  that  when  I  carried  a  strong  white-rubber 


Fig.  102. — Shoulder-joint  amputation.     Pins  and  nibl 
bandage  has  been  removed.     (From  . 


1 1  lurniquet  in  position.     The  Esmarch 
Ijy  H.  J.  Shannon.) 


tube  four  or  five  times  around  the  shoulder  above  these  needles,  making  strong 
traction,  the  compression  was  so  great  that  the  blood  vessels  going  to  the  arm 
were  entirely  occluded  (Fig.  102). 


Fig.  103. — The  same  after  disarticulation  and  ligature  of  the  vessels. 


AMPUTATIONS 


63 


Since  that  date  this  method  has  been  repeatedly  employed  with  invariable  suc- 
cess in  the  control  of  hemorrhage.  After  the  extremity  has  been  exsanguinated 
by  Esmarch's  bandage,  the  pins  should  be  introduced,  the  rubber  constrictor  applied, 
and  the  Esmarch  bandage  removed.  The  incisions  for  the  flap  should  be  made 
to  conform  to  the  conditions  which  demand  the  operation.  When  possible,  the 
ideal  amputation  at  the  shoulder  is  a  circular  incision  through  the  skin  down  to 
the  deep  fascia,  about  four  inches  beyond  the  joint.  A  longitudinal  incision  is  then 
made  from  the  acromion  process  directly  down  to  the  circular  incision,  and  the 
flap  dissected  back  to  the  level  of  the  joint  and  the  latter  disarticulated.  When 
permissible,  after  disarticulation  I  leave  the  tissues  upon  the  inner  aspect  of  the 
humerus  a  little  longer  in  order  to  get  as  much  of  the  blood  vessels  beyond  the  con- 
strictor as  possible.  The  operation  is  completed  with  the  tourniquet  in  position 
(Fig.  103).  Silkworm-gut  sutures  with  a  bundle  of  sterile  catgut  for  capillary 
drainage  will  suffice  for  closing  and  draining  the  wound,  which,  as  a  rule,  should 
be  redressed  about  the  seventh  day. 


Eemoval  of  the  Upper  Extremity  with  All  or  a  Portion  oe  the  Clavicle 

AND  Scapula 

Wlien  it  becomes  necessary  to  remove  portions  of  the  scapula  or  clavicle,  or 
all  of  these  bones,  it  is  advisable  to  tie  the  subclavian  artery  (third  division)  and 
the  transversalis  colli  and  subscapular  branches  of  the  thyroid  axis.  When  the 
disease  extends  so  far  upon  the  shoulder  that  it  is  impossible  to  secure  flaps  suffi- 
cient to  cover  the  exposed  surface,  cut  well  away  from  the  disease  and  allow  the 
wound  to  heal  by  granulation,  relying  upon  subsequent  plastic  procedures  to  cover 
in  the  stump. 

Lower  Extremity 

Amputation  of  the  Toes. — The  same  methods  given  for  the  fingers  should  be 
employed  in  amputation  of  the  toes.  The  long  plantar  flap  is  preferable  in  these 
operations,  not  so  much  for  the  preservation  of  the  more  perfect  tactile  sense  of 
this  surface  in  covering  the  stump,  but  chiefly  to  bring  the  cicatrix  on  top  and 
away  from  pressure.     When  an  amputation  is  necessitated  for  a  lesion  near  the 


/0<1>Q. 


articulation  between  the  first  and  second  phalanges  in  which  only  the  anterior 
extremity  of  the  first  phalanx  is  involved,  section  through  the  bone  should  be  pre- 
ferred to  disarticulation  at  the  metatarso-phalangeal  joint,  provided  that  the  line 
of  section  is  through  the  anterior  third  of  the  phalanx.     Disarticulation  of  two  or 


64  AMPUTATIONS 

more  consecutive  toes  at  the  metatarso-phalangeal  joint  may  be  effected  by  a  con- 
tinuous incision.  Amputation  of  all  the  toes  at  this  articulation  is  performed  as 
follows:  Grasp  and  forcibly  flex  the  toes,  and  make  an  incision,  commencing  just 
posterior  to  the  inner  aspect  of  the  metatarsal  joint  of  the  great  toe,  curving  for- 
Tvard  along  the  side  of  the  iirst  phalanx  to  a  point  as  far  advanced  as  the  web 
between  the  toes,  and  then  across  the  l)ase  of  each  digit  on  this  plane  until  the 
outer  side  of  the  metatarsal  bone  of  the  fifth  toe  is  reached  at  a  point  corresponding 
to  that  at  which  the  incision  was  begun.  With  the  toes  now  fidly  extended,  a 
symmetrical  flap  is  next  cut  along  the  plantar  aspect  by  an  incision  which  almost 
merges  into  the  first  line  at  the  anterior  margin  of  the  web  (Figs.  104,  105). 
Dissect  ^^p  each  flap  as  far  back  as  the  metatarso-phalangeal  articulation,  leaving 
the  tendons  to  be  divided  at  this  point.  The  disarticulation  may  be  best  effected 
Tvith  a  strong  narrow  scalpel,  while  the  ligaments  are  made  tense  by  forced  flexion. 

Second  Method. — A  separate  amputation  may  be  made  for  each  toe. 

Through  the  Metatarsus. — When  the  loss  of  tissue  requires  an  amputation  be- 
hind the  metatarso-phalangeal  articulation,  section  of  one,  or  even  all,  of  the  meta- 
tarsal bones  should  be  effected  rather  than  unnecessarily  sacrifice  any  portion  of 
the  foot  by  disarticulation  at  the  tarso-metatarsal  joint.  The  line  of  section  should 
always  be  as  near  the  anterior  extremity  as  possible,  and  when  it  falls  within  three 
fourths  of  an  inch  from  the  tarso-metatarsal  joint,  a  disarticulation  should  be  made 
at  this  point. 

Amputation  through  the  entire  metatarsus  should  be  made  with  a  long  plantar 
-and  short  dorsal  flap,  so  that  the  scar  will  fall  on  the  dorsum  of  the  foot  and  away 
from  pressure.  The  dorsal  incision  should  be  made  almost  directly  across  the  foot,, 
and  on  a  line  with  the  plane  of  section  through  the  bones.  The  plantar  flap  should 
begin  on  the  inner  sicle  of  the  first  metatarsal  bone,  and  follow  this  forward  as 
far  as  is  necessary  to  secure  a  flap  of  sufficient  length.  It  is  alwa3^s  wise  to  make 
this  a  little  too  long,  so  that  it  may  be  trimmed  down  and  made  to  fit  nicely  as 
the  sutures  are  being  adjusted.  The  incision  is  next  carried  across  the  sole  of  the 
foot  to  the  outer  surface  of  the  metatarsal  bone  of  the  little  toe,  and  back  along  this 
to  the  point  of  junction  with  the  end  of  the  dorsal  cut.  All  of  the  tissues  should 
be  divided  directly  down  to  the  bones  in  this  incision,  and  the  flap  dissected  up, 
keeping  the  knife-point  always  in  contact  with  the  periosteum,  so  that  the  vessels 
may  be  avoided.  After  the  bones  are  sawn  through,  the  lower  flap  is  turned  into 
position  and  suitably  trimmed.  The  vessels  are  next  secured,  the  sutures  applied, 
and  the  drainage-tubes  brought  out  at  each  side. 

At  the  Tarso-metatarsal  Articulation — First  Metatarsal. — Amputation  of  the 
great  toe,  with  disarticidation  of  its  metatarsal  bone  at  the  tarsal  joint,  is  effected 
as  follows :  At  a  point  about  half  an  inch  behind  the  articulation  of  the  metatarsal 
bone  with  the  internal  cuneiform,  and  immediately  between  the  dorsal  and  internal 
lateral  aspects  of  this  bone,  commence  an  incision  which  is  carried  forward  to  the 


phalangeal  junction.  Thence  it  is  continued  around  the  base  of  the  toe,  across  its 
plantar  surface,  and  back  through  the  web  between  the  first  and  second  digits,  and 
back  to  the  end  of  the  straight  incision  over  the  metatarso-phalangeal  joint  (Fig. 
106).     Dissect  the  soft  parts  closely  from  the  bone,  taking  care  not  to  wound  the 


AMPUTATIONS 


65 


plantar  vessels,  and  disarticulate.  The  preservation  of  the  posterior  portion  of 
the  first  metatarsal  bone  is  alwaj^s  desiraljle,  on  account  of  its  giving  insertion  to 
the  peroneus  longus  and  partiall}'  to  the  tibialis  anticus  muscle,  the  former  being 
a  strong  supporter  of  the  transverse  arch  of  the  foot,  and  the  latter  offering  the 
chief  resistance  to  the  sural  miTscles. 

Fifth  Metatarsal. — One  fourth  of  an  inch  behind  the  tubercle  of  the  fifth  meta- 
tarsal, and  over  the  center  of  the  dorsal  aspect  of  this  bone,  commence  an  incision, 
which  is  carried  directly  forward  until  near  the  first  phalanx,  when  an  oval  is 
described  around  the  base  of  the  little  toe  (Fig.  107).  Keep  close  to  the  bone 
in  the  dissection.  The  disarticulation  is  more  easily  effected  by  division  of  the 
peroneus  brevis  and  peroneus  tertius,  and  by  entering  the  articulation  from  the 
outer  side.  The  importance  of  the  posterior  portion  of  this  bone  is  less  than  that 
of  the  metatarsal  bone  of  the  great  toe,  but  it  should  never  be  needlessly  sacrificed. 

One  or  more  of  the  intervening  metatarsal  bones  may  be  removed  in  an  ampu- 
tation of  their  respective  toes  in  practically  the  same  manner  as  the  preceding. 
The  incision  should  be  begun  far  enough  behind  the  tarso-metatarsal  joint  to  thor- 
oughly expose  the  ligaments  and  facilitate  disarticulation — not  an  easy  process 
when  only  a  single  bone  is  to  be  removed.  The  incision  should  be  made  exactly 
along  the  middle  line  of  the  dorsal  aspect. 

Amputation  of  the  entire  metatarsus  should  always  be  made  through  the  articu- 
lar plane  (Lisfranc). 

Method — Dorsal  Incision. — Place  the  thumb  and  index  of  one  hand  respectively 
half  an  inch  behind  the  articulations  of  the  first  and  fifth  metatarsal  bones  with 
the  cuneiform  and  cuboid,  and  at  the  most  convenient  one  of  these  points  com- 
mence the  dorsal  incision,  carrying  it  directly  forward  to  the  base  of  the  meta- 


tarsus, and  then  across  the  foot  one  fourth  of  an  inch  in  front  of  the  tarso-meta- 
tarsal articulation,  finishing  at  the  opposite  side  (Fig.  108).  This  incision  should 
have  a  slight  forward  convexity,  and  should  divide  all  tissues  down  to  the  bones. 
Dissect  the  flap  closely  from  the  periosteum  to  about  one  fo\irth  of  an  inch  behind 
the  line  of  articulation. 

Plantar  Flap. — From  the  same  point  as  for  the  dorsal  incision,  carry  the  knife 
directly  forward  on  the  lateral  aspect  of  the  metatarsal  bone  to  the  metatarso- 
phalangeal joint,  where  the  line  of  incision  should  begin  to  describe  a  curve  until 
the  iuterdigital  wel)  is  reached,  along  which  it  travels  across  the  foot,  and  thence 
back  along  the  opposite  metatarsal  bone  to  the  level  of  the  tarsus  (Fig.  109). 

This  flap  should  be  lifted  by  deep  dissection,  keeping  close  to  the  under  surface 
of  the  bones,  in  order  to  interfere  as  little  as  possible  with  the  vascular  supply.    An 


66 


AjNIPUTATIONS 


assistant  should  now  hold  hoth  flaps  well  back,  while  with  a  narrow,  short  scalpel 
the  disarticulation  is  effected  as  follows: 

Grasp  the  metatarsus  with  one  hand  and  forcibly  depress  it  until  the  ligaments- 
are  put  upon  the  stretch.  Enter  the  knife  just  behind  the  tip  of  the  fifth  meta- 
tarsal bone  and  carry  it  inward  with  a  slight  forward  inclination,  disarticulating 
on  this  plane,  and  in  succession  the  fifth,  fourth,  and  third  bones,  until  the  knife 
is  arrested  by  the  outer  surface  of  the  second  metatarsal.  The  line  of  this  articu- 
lation is  almost  parallel  with  that  just  followed,  but  it  is  placed  from  one  eighth 
to  one  fourth  of  an  inch  posterior  to  it,  and  may  be  readily  found  by  moving  the- 
metatarsal  bone  upon  the  cuneiform.  The  joint  between  the  metatarsal  bone  of  the 
great  toe  and  the  internal  cuneiform  is  aliout  one  fourth  of  an  inch  anterior  to 
that  of  its  fellow,  being  continuous  with  the  line  of  the  three  outer  bones.  The 
flaps  should  now  be  trimmed  and  nicely  fitted,  and  any  ragged  ends  of  tendons- 
clipped  off  by  the  scissors,  after  which  the  vessels  are  tied  and  the  sutures  adjusted,, 
leaving  the  drainage-tubes  out  at  each  angle. 

One  point  of  precaution  is  essential,  namely,  to  avoid  division  of  that  part  of 
the  tendon  of  the  tibialis  anticus  which  is  inserted  into  the  internal  cuneiform  near 
its  metatarsal  articulation.  One  of  the  objections  to  this  operation  is  the  elevation 
of  the  heel,  and  the  consequent  depression  of  the  stump  by  the  action  of  the  sural 
muscles,  which  action  is  practically  unopposed  if  the  insertion  of  the  tibialis  anticus 
is  divided.  Should  this  occur,  or  should  the  heel  be  too  greatly  elevated,  the  tendo 
_  Achillis  should  be  divided  as  in  talipes 

~  equinus. 

Through  the  Tarsus. — When  removaL 
of  any  part  of  the  anterior  row  of  tarsal 
bones  is  required,  the  following  rules- 
should  be  adopted :  If  the  internal  cunei- 
form is  involved  only  on  its  anterior 
articular  surface,  it  may  be  sawn  through 
on  the  line  of  Hey  (Fig.  110).  If  the 
middle  or  external  cuneiform  is  involved 
only  to  a  limited  extent  upon  its  ante- 
rior portion,  as  much  as  one  fourth  of 
an  inch  of  this  surface  may  be  sawn  or 
scraped  off.  Behind  this  limit  a  disar- 
ticulation from  the  scaphoid  should  be 
made.  Through  the  cuboid  the  sec- 
tion should  pass,  as  first  advised  by  Dr. 
S.  F.  Forbes,  of  Toledo,  Ohio  (who  per- 
formed this  operation  in  1863),  through 
the  middle  of  this  bone  on  the  line  of 
the  anterior  surface  of  the  scaphoid 
(Fig.   110). 

Medio-tarsal — Operation  of  Chopart. 
— The  dorsal  incision  is  begun  on  a 
level  with  and  an  inch  posterior  to  the 


-Pirogoff. 


Fig.  110. 


.^MPUTATIOXS 


67 


tip  of  the  base  of  the  fifth  metatarsal  bone  (for  the  adirlt  foot).  This  point 
is  about  one  fourth  of  an  inch  behind  tlie  articulation  between  the  cuboid  and 
calcaneuni  (Figs.  107  and  111).  With  a  slight  forward  eonvesit}'  the  incision 
is  carried  across  the  top  of  the  foot  to  the  posterior  margin  of  the  tuberosity 
of  the  scaphoid,  and  then  directly  back  from  one  fourth  to  half  an  inch 
(Fig.  106).  The  skin,  tendons,  vessels,  and  nerves  are  divided  on  this  line, 
and  the  flap  lifted  mitil  the  joints  between  the  astragalus  and  scaphoid  and 
the  calcaneum  and  cuboid  are  well  exposed.  From  the  ends  of  this  first  incision 
a  long  plantar  flap  is  fashioned  by  cutting  forward,  as  in  shaping  the  flap  for  the 
operation  of  Lisfranc  (Figs.  106,  107).  Disarticulation  is  effected  with  a  short, 
strong  scalpel,  while  forcible  extension  is  employed.  The  flaps  are  now  to  be  prop- 
erly trimmed,  and  the  vessels  secured.  Division  of  tlie  tendo  Achillis  may  be  done 
later.  When  required,  this  ojDeration  may  be  modified  by  sawing  ofi:  the  anterior 
half-inch  of  the  astragalus  and  calcaneum.  The  incisions  are  practically  the  same. 
Calcaneo-astragaloid  DisarticiiJation. — ■\\n-ien  in  an  amputation  of  the  foot  at 
the  medio-tarsal  joint  it  is  discovered  that  the  os  calcis  must  also  be  removed,  and 


Fig.  112. — (After  Malgaigne.) 


Fig.  113.— (.\fter  Malgaigne.) 


if  the  astragalus  is  sound,  the  subastragaloid  operation  should  be  preferred  to  the 
amputation  of  Sj'me  at  the  tibio-tarsal  joint.  The  inequalities  on  the  under  surface 
of  the  astragalus  may  be  removed  with  the  chisel  or  saw.  By 
this  method  a  shortening  of  about  two  inches  is  prevented,  and 
experience  has  shown  that  a  useful  stump  results.  Moreover, 
the  degree  of  mobility  maintained  at  the  tibio-astragaloid  ar- 
ticulation adds  to  the  ease  and  comfort  of  locomotion. 

Seize  the  foot  with  the  left  hand,  and  with  a  strong  scalpel 
commence  the  incision  by  dividing  the  skin  and  tendo  Achillis 
just  at  the  level  of  the  upper  surface  of  the  os  calcis.  From 
this  point  the  incision  is  continued  along  the  fibular  side  of 
the  foot  forward,  dividing  everything  do^vn  to  the  bone,  and 
curving  slightly  downward  until,  as  it  passes  below  the  tip 
of  the  external  malleolus,  it  is  four  tenths  of  an  inch  below 
this  point  (Fig.  112).  The  line  of  incision  is  now  carried 
direeth'  forward  until  near  the  tuberosity  at  the  base  of  the 
fifth  metatarsal  bone,  where  it  curves  to  the  dorsum  of  the 
foot,  crossing  to  the  inner  side  over  the  anterior  edge  of  the 
scaphoid,  and  then  straight  down  and  under  the  foot  a  half 
inch  bej'ond  the  middle  of  the  sole  (Figs.  113,  114).  From 
this  point  a  straight  incision  is  made  directly  back  to  the  point 
of  beginning  at  the  inner  edge  of  the  tendo  Achillis  (Fig.  114). 
Lift  the  plantar  flap  by  deep  and  careful  dissection  from  the 
bone,  leaving  nothing  but  the  periosteum,  until  the  calcaneo- 
astragaloid  articulation  is  well  exposed.  The  flaps  being  held  by  an  assistant,  the 
disarticulation  is  begun  by  opening  the  astragalo-scaphoid  joint  and  removing  the 
anterior  part  of  the  foot  at  the  medio-tarsal  joint.  The  os  calcis  should  now  be  seized 
with  a  lion-tooth  forceps,  and  tlie  disarticulation  of  this  bone  effected.  The  exposed 
tendons  should  be  smoothly  divided  with  the  scissors  at  the  higher  portions  of  the 


Fig.  114.— (After  Mal- 
gaigne.) 


68 


AMPUTATIONS 


incision.    After  deligation  of  the  vessels  tlie  flap  is  properly  trimmed  and  sutured, 
the  cicatrix  falling  upon  the  dorsal  and  external  lateral  aspects  of  the  stump. 

Amputation  of  the  Foot—Tibio-tarsal  {Syme's). — When  the  astragalus  must" 
be  removed,  together  with  the  foot,  the  amputation  of  Syme,  which  involves  a 
disarticulation  of  the  tibio-astragaloid  joint,  and  a  subsequent  section  of  the  ar- 
ticular surfaces  of  the  tibia  and  fibula,  should  be  made.  In  its  successful  per- 
formance certain  precautions  are  necessary,  chief  among  which  is  the  preservation 
of  the  proper  vascular  supply  to  the  posterior  flap.  The  failure  to  appreciate  the 
importance  of  making  the  plantar  incision  far  enough  forward,  as  laid  down  by 
Syme,  has  brought  this  procedure  somewhat  into  disrepute,  for  Prof.  Stephen 
Smith,  in  his  comprehensive  report,  says  the  necessity  for  reamputation  is  three 
per  cent  greater  in  this  than  in  any  other  amputation. 

In  1876  '  the  author  demonstrated  that  the  arterial  distribution  to  the  calcaneo- 
plantar  flap  was  chiefly  derived  from  the  external  plantar  artery,  and  from  the 
posterior  tibial  so  near  the  bifurcation  of  this  vessel  into  its  terminal  branches, 
that  any  line  of  incision  in  the  formation  of  this  flap  which  necessitated  the  appli- 


FiG.  115. — Diagram  showing  the  arterial  supply  to  the  calcanean  region,  on  tlie  tibial  side  of  the  foot. 
(Drawn  by  the  author,  from  tlie  avercige  of  eiglitj'-seven  dissections.)  m.  Internal  malleolus. 
pmc  n,  Tibio-tarsal  quadrilateral,  the  surgical  region  of  this  articulation,  k.  Posterior  tibial  artery, 
o.  Its  point  of  bifurcation  into  g,  Internal  plantar,  and  /,  External  plantar  artery,  i  i  i,  Calcanean 
branches  of  external  plantar,  t,  Articular  branches  from  posterior  tibial,  h,  Articular  branch  from 
internal  plantar,  g.  Tendon  of  tibialis  posticus  muscle,  r.  Tendon  of  flexor  longus  digitorum. 
s.  Tendon  of  flexor  longus  poUieis.  m  c.  The  line  of  incision  of  Gross,  -m  l,m,d,m,e,m  e,  Lines  of 
incision  showing  that  the  nearer  the  incision  approaches  the  heel,  the  more  danger  is  incurred  of 
cutting  off  the  principal  blood-supply  to  the  calcanean  flap,  in  amputation,  ni  n,  Line  crossing  the 
usual  point  of  bifurcation  of  the  posterior  tibial,     in  a,  vt  h,  Anterior  incision. 

cation  of  a  ligature  at  or  very  near  its  bifurcation  was  not  justifiable.  The  slough- 
ing so  often  met  with  at  this  point  is  caused  by  carrying  this  incision  too  far 
back  toward  the  tuberosity  of  the  calcaneum.  The  arterial  supply  is  shown  in 
Fig.  115. 

Modified  Procedure. — With  the  foot  held  at  an  angle  of  ninety  degrees  to  the 
axis  of  the  leg,  place  the  thumb  at  the  tip  of  one  malleolus,  and  the  index  at 
the  other,  and  from  the  center  of  the  malleolus  internus  carry  an  incision  directly 
across  the  sole  of  the  foot  to  a  point  one  fourth  of  an  inch  anterior  to  the  tip  of 
the  malleolus  externus.  This  incision  should  divide  all  the  tissues  to  the  bones, 
and,  as  will  be  seen  in  Figs.  116  and  117,  its  perpendicular  portion  descends  in 
a  direction  slightly  anterior  to  the  axis  of  the  tibia.  The  ends  of  this  cut  are 
united  by  a  second,  which  arches  sharply  upward  about  on  the  line  of  section  of 
the  bones,  and  should  also  divide  tendons  and  all  intervening  structures,  opening 
into  the  joint.  The  foot  shoifld  now  be  flrmly  grasped  and  extended,  so  as  to 
make  tense  the  anterior  ligament  of  the  ankle,  which  is  easily  divided.  Carrying 
the  knife  to  either  side  of  the  articidar  surfaces  of  the  astragalus,  the  lateral  liga- 

«  "Essays  in  Surgical  Anatomy  and  Surgery,"  William  Wood  &  Co.,  1879. 


AJIPUTATIONS 


69 


merits  are  cut,  and  the  joint  thus  wicleh'  exposed.  An  assistant  now  holds  and 
depresses  the  foot,  while  the  operator  carefully  dissects  the  tissues  closely  from 
the  astragalus  and  calcaneum.  Care  should  be  taken  not  to  bruise  the  flap  by 
too  great  traction.  In  dissecting  along  the  inner  surface  of  the  ankle,  the  knife 
should  be  kept  close  to  the  bones,  so  that  when  the  lesser  process  of  the  calcaneum 
is  reached  it  will  slide  behind  and  under  this  process,  passing  between  it  and  the 
flexor  tendon  and  the  vessels.     If  this  jprecaution  is  not  taken,  the  arteries  may 


be  wounded  and  the  nutrition  of  the  flap  seriously  impaired.  As  the  dissection 
proceeds,  the  foot  is  further  depressed,  and  the  tendo  Achillis  sej^arated  from  its 
insertion  into  the  tuberosity  of  the  calcaneum,  in  doing  which  care  must  be  taken 
not  to  button-hole  the  flap.  The  posterior  portion  of  the  os  calcis  may  now  be 
brought  through  the  joint,  and  the  dissection  continued  in  this  direction  or  flnished 
by  working  back  along  the  iinder  surface  of  this  bone.  After  the  foot  is  removed, 
the  flaps  are  lifted  from  the  tibia  and  fibula  until  a  section  of  these  bones  can  be 


Fig.  lis.  Fig.  119. — Stump  after  the  author's  modification 

of  Syme's  amputation. 

made  just  on  the  level  of  the  anterior  articular  margin  of  the  tibia  (Fig.  118).  It 
is  not  necessary  to  remove  the  articular  surface.  The  flaps  should  now  be  trimmed 
aud  fitted,  and  the  vessels  tied.  As  the  sutures  are  applied,  it  will  be  noticed  that 
there  is  a  redundancy  of  tissue  in  the  long  flap,  leaving  a  cup-shaped  cavity;  but 
this  can  be  thoroughly  drained  from  the  angles  of  the  wound,  and  disappears"  when 
the  stump  is  healed  "(Fig.  119). 

The  great  improvement  in  the  construction  of  artificial  apparatus  has  made  the 
various  osteoplastic  operations  of  Pirogoff,  Le  Fort,  and  others  unnecessary.  The 
stump  after  the  modified  SjTne's  (Fig.  119)  will  prove  most  satisfactory. 


70  AMPUTATIONS 

Summary. — In  amputations  of  the  foot  the  following  rules  should  be  observed: 
The  terminal  phalanges  of  all  the  toes  should  be  removed  by  disarticulation  when 
it  becomes  necessary  to  remove  a  23ortion  of  the  entire  thickness  of  these  bones. 
The  same  rule  applies  to  all  the  second  phalanges,  except  that  of  the  great  toe, 
whicli  should  be  sawn  through  at  any  point  anterior  to  its  middle.  If  a  section 
posterior  to  this  is  required,  disarticulate  from  the  metatarsal  bone.  What 
has  been  said  of  the  second  phalanx  of  the  great  toe  applies  with  equal  force 
to  the  proximal  phalanges  of  all  the  other  toes. 

K"one  of  the  metatarsal  bones  should  be  disarticulated  from  the  tarsus  when 
a  section  is  possible  not  less  than  three  fourths  of  an  inch  anterior  to  each  tarso- 
metatarsal Joint. 

When  a  section  jDosterior  to  this  line  is  required,  a  tarso-metatarsal  disarticu- 
lation should  be  effected.  Hey's  operation  is  only  justifiable  when  the  anterior 
face  of  the  internal  cuneiform  is  diseased.  As  much  as  the  anterior  fourth  of 
each  cuneifonn  bone,  and  the  anterior  half  of  the  cuboid,  may  be  sawn  off,  in 
preference  to  the  sacrifice  of  the  bony  frame\^'ork,  \>\  Forbes's  or  Chopart's 
operation. 

When  the  cuneiform  bones  must  be  removed,  and  the  posterior  half  of  the 
cuboid  is  sound,  Forbes's  ojDeration  should  be  preferred  to  Chopart's.  Chopart's 
procedure  is  next  in  order.  The  subastragaloid  operation  follows  and  then  Syme's 
as  modified.     (See  Fig.  110.) 

Leg. — Amputation  at  any  poi-tion  of  the  leg  above  the  line  of  section  in  Syme's 
operation  may  be  made'  as  follows : 

1.  Modified  Circular  Skin  Flap. — x\t  a  sufficient  distance  beyond  the  point  at 
which  the  bones  are  to  be  divided  make  a  circular  cut  through  to  the  deep  fascia, 
split  the  flap  directly  over  the  fibula,  up>  to  the  point  of  section  through  the  bones, 
and  carefully  dissect  up  the  cuff.  When  the  flap  is  reflected,  at  the  level  of  its  base 
divide  all  the  soft  tissues  squarely  down  to  the  bones,  which  are  next  savm  through. 
The  spine  of  the  tibia  should  be  trimmed  down,  to  prevent  too  acute  pressure  and 
sloughing  of  the  skin  at  this  point,  a  not  infrequent  occurrence  when  this  precau- 
tion is  omitted.  The  drainage  is  at  the  fibular  side,  and,  as  the  leg  should  be 
elevated,  the  tube  should  come  out  at  the  highest  point  of  the  perpendicular 
incision. 

2.  Method  of  Prof.  Stephen  Smith. — Commence  an  incision  in  the  center  of 
the  anterior  surface,  and  carry  it  downward  along  the  side  of  the  leg,  so  as  to 
make  a  slightly  curved  flap,  with  its  convexity  below;  when  the  incision  passes 
over  the  prominent  part  of  the  leg  toward  the  posterior  surface,  incline  it  upward 
\mii\  the  middle  of  the  limb  is  reached,  where  it  should  be  continued  directly  up 
to  the  point  at  which  the  bone  is  to  be  divided;  make  a  similar  incision  on  the 
opposite  side  (Fig.  130)  :  the  flaps,  consisting  of  the  skin  and  fascia,  are  dissected 


(After  Stephen  Smith.) 


upward  about  an  inch,  at  which  point  the  muscles  are  divided  squarely  down  to 
the  bones.  After  the  bones  are  divided,  the  hood  is  brought  over  the  stump  and 
sutured,  leaving  the  drainage  at  the  itpper  part  of  the  posterior  incision. 

In  very  emaciated  subjects,  to  forestall  the  liability  of  sloughing  in  the  flaps,  the 
first  circular  cut  should  go  directly  through  all  the  tissues  down  to  the  bones,  and 
the  perpendicular  incision  along  the  fibula  also  down  to  tliis  bone.  All  the  tissues 
should  then  be  lifted  closely  from  the  periosteum  and  interosseus  membrane,  form- 
ing a  solid  flap,  reflected  up  to  the  point  at  which  the  bones  are  to  be  divided. 


A3IPUTATI0XS 


71 


The  time  to  apply  an  artificial  limb  is  just  as  soon  after  an  amputation  as 
it  can  be  borne.  Waiting  means  only  a  loss  of  time,  and  causes  the  stump  to 
become  enervated  from  want  of  use. 

If  amputation  is  done  for  malignant  disease,  it  is  better  to  wait  longer  in 
order  to  see  if  there  will  be  a  recurrence  of  the  neoplasm. 

"When  the  line  of  amputation  approaches  nearer  than  three  inches  from  the 
Tipper  articular  surface  of  the  tibia,  a  complete  disarticulation  at  the  laiee  should 
be  performed.  At  or  below  this  point  the  upper  portion  of  the  bone  should  be 
jpreserved,  and  the  end  of  the  fibula  exsected.    After  recovery  from  the  operation  it 


Fig.   121. — (Modified  from  Esmarcii  )     ^- 


Tvill  be  found  that  the  tibia  is  flexed  upon  tlie  femur,  so  that,  in  the  adjustment 
of  an  artificial  limb,  the  chief  pressure  may  be  comfortably  borne  upon  the  normal 
tissues  in  front  of  the  patella  and  the  tuberosity  of  the  tibia.  The  greater  pres- 
sure in  any  prothetic  apparatus  used  after  amj)utation,  at  or  above  the  knee,  falls 
-upon  the  ischio-perineal  region.^ 

'  The  older  operations,  which  consisted  in  making  a  long  and  a  short  flap  on  opposite  sides  of 
the  leg,  are  now  fallen   into  general  disuse. 
They  are  the  methods  of  Teale,  Lee,  Sedillot, 
and  others. 

Method  of  Teale — Long  and  Short  Rectan- 
gular Flaps. — ^The  long  flap,  folding  over  the 
end  of  the  bone,  is  formed  of  parts  generallj' 
devoid  of  large  blood  vessels  and  nerves,  which 
structures  are  left  in  the  short  flap.  The  size 
of  the  long  flap  is  determined  by  the  circum- 
ference of  the  limb  at  the  place  of  amputation, 
its  length  and  breadth  being  each  equal  to  half 
the  circumference  of  the  limb  at  this  point. 
The  short  flap  is  one  fourth  as  long  as  the  other. 
The  incisions  and  stump  after  Teale's  method, 
are  shown  in  Fig.  122. 

Sedillot's  Method — Long  Fib- 
ular, Short  Tibial,  Flap. — Oppo- 
site the  point  at  which  the  bones 
are  to  be  divided  insert  a  long, 
thin  amputating  knife,  the  point 
of  which  shall  graze  the  spine  of 
the  tibia  and  the  outer  surface  of 
the  fibula,  and  come  out  through 
the  outer  aspect  of  the  calf.  Cut 
downward  close  to  the  bones,  and 
make  a  long,  rounded  flap.  The 
short  flap  is  made  by  an  incision 
with  a  slight  downward  convex- 
ity  (Fig.  123). 

Lee's  Method. — ^The  length  of 
the  flaps  is  determined  as  in 
Teale's  amputation.  The  long 
flip  is  posterior,  and  includes  the 
skin  and  sural  muscles.  The 
deep  muscles  and  the  vessels  are 
divided  squarely  at  the  base  of 
the  flap  (Fig.  124).  Fig.  124. — (.^shhurst's  "Encyclopaedia.") 


Fig.  125. — Transverse  section  of  the  right  leg  just  above  the  ankle-joint,  showing  the  relation  of  the  parts 
on  the  plane  of  section  through  the  malleoli  in  Syme's,  Plrogoff's,  Le  Fort's,  CJunther's,  and  Bruns's 
amputations.  Looking  at  the  surface  nearest  the  body.  1,  Extensor  longus  digitorum.  2,  An- 
terior tibial  vessels  and  nerve.  3,  Extensor  proprius  pollicis.  4,  Tibialis  anticus.  5,  Internal 
saphena  vein.  6,  Tibialis  posticus.  7,  Flexor  longus  digitorum.  8,  Posterior  tibial  artery,  veins, 
and  nerve.  9,  Flexor  longus  pollicis.  10,  Tendo  Achillis.  11,  External  cutaneous  nerves.  12, 
Peroneus  brevis.     13,  Peroneus  longus. 


Fig.  126.^Section  through  lower  third  of  right  leg.     Looking  toward  the  center.   1,  Anterior  tibial  nerve, 
artery,  and  veins.     2,  Posterior  tibial  artery,  veins,  and  nerve.     3^  Peroneal  artery  and  veins. 

72 


AMPUTATIONS 


73 


Knee-joint. — First  Method — Modified  Circular  Shin  Flap. — About  three  inches 
below  the  patella  make  a  circialar  sweep  around  the  leg,  dividing  the  skin  and 
fascia.  Join  this  by  a  perpendicular  incision  in  the  middle  line  of  the  jjosterior 
aspect  of  the  limb,  extending  through  the  skin  and  fascia,  and  at  least  as  high 
as  to  the  level  of  the  top  of  the  patella.  Dissect  the  skin  back  carefull}^,  keeping 
close  to  the  anterior  surface  of  the  patella,  as  the  skin  over  tliis  bone,  is  usually 
very  thin.  It  is  not  necessary  to  dissect  the  cufE  as  high  on  the  lateral  and 
posterior  aspects  as  in  front,  since  the  anterior  incision  is  made  to  allow  of  the 
removal  of  the  patella  and  dissection  of  the  STOOvial  sac  just  above  it.  Divide 
the  tendon  of  the  qviadriceps  at  the  upper  limit  of  the  patella,  turn  this  down, 


Fig.  127. — Section  through  the  middle  of  the  riglit  lug.  Looking  from  below  upward.  1,  Anterior  tibial 
artery,  veins,  and  nerve.  2,  Posterior  tibial  arterj-,  veins,  and  nerve.  3,  Peroneal  artery  and  veins. 
4,  Long  saphena  vein  and  nerve.     5,  Musculo-cutaneous  nerve.      6,  Short  saphena  vein  and  nerve. 


cut  the  lateral  ligaments  and  capsule  along  the  edges  of  the  condyles  of  the  femur, 
flex  the  leg  strongly  on  the  thigh,  divide  the  crucial  ligaments,  and,  as  soon  as 
the  posterior  ligament  of  Winslow  is  exposed,  introduce  a  long  knife  and  remove 
the  leg  by  cutting  squarely  through  the  soft  tissues  at  the  back  of  the  articulation. 
A  cloth  retractor  is  now  applied  and  a  slice  of  bone  removed  with  the  saw,  leaving 
a  smooth  surface.  Should  the  articular  end  of  the  femur  be  diseased,  the  section 
may  be  made  high  enough  to  remove  this,  provided  the  saw  does  not  enter  the 
medullary  canal.  With  the  cutting-forceps  round  off  the  sharp  edges  of  bone,  tie 
the  vessels,  and  close  the  flaps. 

Second  Method    {Operation  of  Prof.   Stephen  Smith). — With  a  large  scalpel 
commence  an  incision  about  an  inch  below  the  tubercle  of  the  tibia,  and  cut  to. 


74 


AMPUTATIONS 


the  bone;  carry  it  downward  and  foi-ward  beyond  the  curve  of  the  side  of  the 
leg,  thence  inward  and  backward  to  the  middle  of  the  leg,  thence  iipward  to  the 
middle  of  the  popliteal  space;  repeat  this  incision  npon  the  opposite  side;  raise 
the  flap,  consisting  of  all  the  tissues,  down  to  the  bone  until  the  articulation  is 
reached,  divide  the  ligaments,  and  remove  the  leg  as  in  the  previous  operation. 
The  flap  should  be  lifted  from  tlie  patella,  and  this  bone  removed. 

"  Care  should  be  taken  that  the  incision  is  iuclined  moderately  forward  down 
to  the  curve  of  the  side  of  the  leg,  to  secure  ample  covering  for  the  condyles,  and 
that  upon  the  internal  aspect  it  should  have  additional  fullness  for  the  purpose 
of  tasuring  sufficient  flap  for  the  internal  or  larger  condyle"   ( Smith) .^ 


Fig.  128. — Section  through  upper  third  of  right  leg.  Surface  nearest  the  bod}^  1,  Anterior  tibial  vessels 
and  nerve.  2,  Posterior  ditto.  3,  Peroneal  vessels.  4,  Musculo-cutaneous  nerve.  5,  Internal 
saphena  vein  and  nerve. 

After  the  flaps  are  stitched  the  drainage-tube  makes  its  exit  through  the 
upper  posterior  angle  of  the  wound. 

When  in  amputation  near  the  Icnee  the  femur  is  the  seat  of  osteomyelitis,  the 
indications  are  to  thoroughly  cleanse  the  canal  by  means  of  a  long  Volkmann's 
spoon  and  irrigate  with  sublimate  solution;  introduce  a  long  drainage-tube  the 
full  length  of  the  canal  and  bring  this  out  through  the  flap  exactly  in  line  with 
the  axis  of  the  canal  (Fig.  129). 

'  The  osteoplastic  operation  of  Gritti,  in  which  the  under  surface  of  the  patella  is  freshened 
and  attached  to  the  end  of  the  femur,  is  not  advised. 


AMPITATIOXS 


75 


In  tills  -n-ay  the  danger  of  a  higher  amputation  is  avoided  and  a  longer  stump 
secured.     In  iyro  instances  of  amputation  just  above  the  knee,  after  exsection  of 

this  joint  in  -which  osteomyelitis  occurred  in 
the  femur,  I  carried  out  this  practice  suc- 
cessfully. 

Irrigation  through  the  tube  should  he 
practiced  about  the  seventh  day  and  every 
three  or  four  days  after  this,  and  the  tube 
gradually  shortened. 

Thigh. — The  method  to  be  selected  in 
amputations  through  the  lower  two  thirds  of 
the  thigh  will  depend  upon  the  size  of  the 
member  at  the  point  of  election.  In  limbs 
of  ordinary  size,  and  particularly  in  emaci- 
ated persons,  the  operation  advised  in  the 
arm  shoidd  be  followed  here. 

Fiist  Method. — Make   a   circular  incision 

through  the  skin  and  fascia,  Joined  by  a  per- 

FiG.  129.  pendicular  cut  on  the  lower  external  aspect 

of  the  limb.     Dissect  up   the  flap  from  the 

muscles,   and  divide  all  the  remaining  soft  tissues   squarely 

at    the    point    of    section    of    the    bone.      Suture    the    flap, 

and  drain  from  the  outer  upper    (and,  if  necessary,  lower) 

angle. 

Second  Method. — Below  the  line  of  section  through  the 
femur,  at  a  distance  sufficient  to  furnish  an  ample  flap,  by 
a  circular  incision  divide  the  integument  down  to  the  mus- 
cles, allow  the  skin  to  retract,  and  at  the  line  of  retraction 
divide  the  remaining  soft  tissues  doATi  to  the  bone.  On  the 
anterior  and  external  aspect  of  the  thigh,  by  a  perpendicular 
incision  extending  as  high  as  the  point  of  section  of  the  bone, 
divide  everything  to  the  bone,  and  from  the  periosteum,  with 
a  dry  dissector,  lift  the  solid  flap.  Apply  the  cloth  retractor 
and  saw  through  the  bone.  As  the  stump  is  placed  in  an 
elevated  position,  with  the  thigh  also  abducted  and  rotated 
outward,  the  drainage  is  naturally  at  the  upper  angle  of  the 
perpendicular  incision. 
At  the  Hip-joint.^ — Disarticulation  at  the  hip-joint  is  by  far  the  most  for- 
midable in  the  list  of  amputations.  In  1S81  Prof.  John  Ashhurst,  Jr.,  wrote: 
"  The  removal  of  the  lower  limb  at  the  coxo-femoral  articulation  may  be  properly 
regarded  as  the  gravest  operation  that  the  surgeon  is  ever  called  upon  to  per- 
form, and  it  is  only  within  a  comparatively  recent  period  that  it  has  been  accepted 
as  a  justifiable  procedure.    The  most  pressing  risk  is  that  of  heemorrhage." 

In  1890  I  applied  for  the  first  time,  and  with  success,  in  an  amputation  at  the 
Hp-joint,  the  method  which  I  had  used  for  more  than  a  year  previous  in  amputation 
at  the  shoulder- joint.  Since  that  date  I  have  performed  the  operation  a  number 
of  times,  and  it  has  been  done  in  hundreds  of  instances  by  other  operators.  The 
method  is  as  follows: 

The  patient  should  be  placed  with  the  sacrum  resting  upon  the  comer  of  the 
operating  table,  the  sound  limb  and  arms  being  wrapped  with  cotton  batting  and 
thoroughly  protected  from  unnecessary  loss  of  heat.     The  limb  to  be  amputated 

'At  Bardstown,  Ky.,  in  Augiist,  1806,  Dr.  Walter  Brashear  amputated  at  the  hip  in  a  negro 
lad,  seventeen  years  of  age,  on  account  of  a  severe  fracture  of  the  femur  and  laceration  of  the 
soft  parts.  A  circular  incision  was  made,  the  miiscles  di^ded  well  below  the  hi|3-joint,  and  the 
vessels  secured  as  the  operation  progressed.  Then  a  longitudinal  incision  along  the  outer  side  of 
the  limb  exposed  the  remainder  of  the  bone,  which,  being  freed  from  its  muscular  attachments, 
was  disarticulated  at  the  socket  (Prof.  D.  W.  Yandell,  "American  Practitioner  and  Xews,"  1890). 
Dieffenbach's  name  has  been  prominently  associated  with  this  operation  among  surgeons,  but 
Dieffenbach  did  not  take  his  degree  in  medicine  until  1822,  sixteen  years  after  the  pioneer  Ken- 
tuckian  had  performed  his  operation,  which  was  the  first  hip-joint  amputation  in  the  United  States. 


76 


AMPUTATIONS 


should  be  emijtied  of  blood  hj  elevation  of  the  foot  and  by  the  application  of  the 
jEsmarch  bandage,  commencing  at  the  toes.  Under  certain  circumstances,  the 
bandage  can  only  be  partially  applied.  When  a  tumor  exists,  or  when  septic  infil- 
tration is  present,  pressure  should  be  exercised  only  to  within  five  inches  of  the 
diseased  portion  for  fear  of  driving  the  septic  material  into  the  vessels.  After 
injuries  with  great  destruction — crushing  or  pulpefaction — one  must  generally 
trust  to  elevation,  as  the  Esmarch  bandage  cannot  always  be  applied.  While  the 
member  is  elevated,  and  before  the  Esmarch  is  removed,  the  rubber-tubing  con- 
strictor is  applied.     The  object  of  this  constriction  is  the  absolute  occlusion  of 


Fig.  130. — Section  through  the  right  femur  at  the  condyles  and  at  the  middle  of  the  patella.  Looking  at 
the  central  surface  as  exposed  after  amputation  at  this  point.  1,  Popliteal  artery,  vein,  and  internal 
popliteal  nerve.  2,  External  popliteal  or  peroneal  nerve.  The  capsule  and  the  synovial  cavities 
are  admirably  shown,  as  well  as  the  bursa  mucosa  paiellce. 

every  vessel  above  the  level  of  the  hip-joint,  permitting  the  disarticulation  to  be 
completed  and  the  vessels  secured  without  ha?morrhage  and  before  the  tourniquet 
is  removed.  To  prevent  any  possiljility  of  the  tourniquet  slipping,  I  employ  two 
large  steel  needles  or  skewers,  three  sixteenths  of  an  inch  in  diameter  and  ten  inches 
long,  one  of  which  is  introduced  one  fourth  of  an  inch  below  the  anterior  supe- 
rior spine  of  the  ilium  and  slightly  to  the  inner  side  of  this  prominence,  and  is 
made  to  traverse  superficially  for  about  three  inches  the  muscles  and  fascia  on 
the  outer  side  of  the  hip,  emerging  on  a  level  with  the  point  of  entrance  (Fig.  131). 
The  point  of  the  second  needle  is  thrust  through  the  skin  and  tendon  of  origin 
of  the  adductor  longus  muscle  half  an  inch  below  the  crotch,  the  point  emerging 


a:mputatioxs 


an  inch  below  the  tuher  ischii.  The  points  should  he  sliielded  at  once  with  a 
cork  to  prevent  injury  to  the  hands  of  the  operator.  Ko  vessels  are  endangered 
by  these  skewers.     A  mat  or  compress  of  sterile  gauze,  about  two  inches  thick 


Fig.  131. — Hip-joint  amputation.    Pins  and  rubber-tube  tourniquet  in  position.    The  Esmarch  bandage 

has  been  removed. 

and  four  inches  square,  is  laid  over  the  femoral  artery  and  vein  as  they  cross  the 
brim  of  the  pelvis;  over  this  a  piece  of  strong  white-rubber  tubing,  half  an  inch 
in  diameter  when  unstretched  and  long  enough  when  in  position  to  go  five  or 
sis  times  around  the  thigh,  is  now  wound  very  tightly  aroimd  and  above  the  fixa- 


Fig.  132, — The  same,  showing  the  soft  parts  dissected  from  the  bone  and  the  capsule  exposed. 


78 


AMPUTATIONS 


tion  needles  and  tied.  If  the  Esmarch  bandage  has  been  employed,  it  is  now 
removed.  Excepting  the  small  quantity  of  blood  between  the  limit  of  the  Esmarch 
bandage  and  the  constricting  tnbe,  the  extremity  is  bloodless  and  will  remain  so. 


Fig.   133. — The  same,  wifli  the  disarticulation  complete.     Constrictor  still  in  position. 


Fig.  134. — The  operation  completed. 


In  the  formation  of  the  flaps,  the  surgeon  must  be  guided  by  the  condition 
of  the  parts  within  the  field  of  operation.  Wiien  permissible,  the  following  method 
seems  ideal: 

About  six  inches  below  the  tourniquet  a  circular  incision. is  made   down  to 


.\-MPUTATIOXS 


79 


tlie  muscles,  and  this  is  joined  by  a  longitudinal  incision  commencing  at  the 
tourniquet  and  passing  over  the  trochanter  major.  A  cuff  that  includes  every- 
thing down  to  the  muscles  is  dissected  off  to  near  the  level  of  the  ti-ochanter  minor. 
At  about  this  levelj  the  remaining  soft  parts,  together  Tvith  the  vessels,  are  divided 


Fig.  135. — Section  through  right  thigh  at  Hunter  s  canal.  Looking  at  the  surface  attached  to  the  body. 
1,  Femoral  vessels  and  long  saphenous  ner\-e.  2,  Great  sciatic  ner\-e  and  arteria  conies.  3,  Long 
saphenous  vein. 

squarely  down  to  the  bone  by  a  circular  cut  (Fig.  132).  At  this  stage  of  the  opera- 
tion the  central  ends  of  the  divided  superficial  and  deep  femoral  veins  as  -n-ell  as 
arteries  are  in  plain  view  and  should  now  be  tied  with  good-sized  catgut.  This 
done,  the  disarticulation  is  rapidly  completed  by  lifting  the  muscular  insertions 
from  the  trochanters  and  digital  fossa,  keeping  very  close  to  the  bone  with  knife 
or  scissors  and  holding  the  soft  parts  away  with  retractors.     The  capsular  liga- 


80 


AMPUTATIONS 


ment  is  now  exposed  and  divided,  and,  by  forcible  elevation,  adduction,  and  rota- 
tion of  the  femur,  it  is  widely  oiDened,  the  ligamentnm  teres  ruptured,  and  the 
caput  femoris  dislocated  (Fig.  133).  If  properly  conducted  up  to  this  poiat,  not 
a  drop  of  blood  has  escaped  except  that  wliich  was  in  the  limb  below  the  con- 


Fig.  136. — Section  through  left  thigh  at  its  middle.  Looking  at  the  surface  attached  to  the  body.  1, 
Superficial  femoral  artery,  vein,  and  saphenous  nerve.  2,  Great  sciatic  nerve,  and  the  arteria  comes 
nervi  ischiadici.  3,  Terminal  branch  of  profunda  femoris.  4,  Descending  branch  of  external  circum- 
flex.    5,  Long  saphenous  vein. 


stricter  when  this  was  applied.  The  remaining  vessels  which  require  the  ligature 
should  now  be  sought  for  and  secured.  They  are,  first,  the  saphena  vein,  which, 
on  account  of  its  proximity  to  the  main  trunk,  should  be  tied;  the  sciatic  artery, 
which  will  be  found  near  the  stump  of  the  sciatic  nerve;  the  ohturator,  which  is 
situated  between  the  stump  of  the  adductor  brevis  and  magnus,  usually  about 
half-way  from  the  center  of  the  shaft  of  the  femur  to  the  inner  side  of  the  thigli, 
the  vessel  being  on  a  level  with  the  anterior  surface  of  the  femur;  the  descending 
tratiches  of  the  external  circumflex,  two  or  three  in  number,  usually  found  about 
an  inch  and  a  half  outward  and  downward  from  the  main  femoral  vessels  beneath 
the  rectus  and  in  the  substance  of  the  crurseus  and  vastus  externus.  The  descend- 
ing hranclies  of  the  internal  circumflex  are  insignificant  and  are  usually  found  on 


AMPUTATIONS 


81 


the  level  of  the  femoral  vessels  in  the  substance  of  the  adductor  longus  and  between 
it  and  the  adductor  brevis  and  pectineus  (see  Fig.  138). 

In  tying  the  larger  femoral  vessels,  I  make  it  a  rule  to  dissect  both  the  super- 
ficial and  deep  femoral  stumps  back  from  a  half  to  three  fourths  of  an  inch  so 
that  I  can  apply  the  ligature  behind  any  of  their  branches  which  may  have  been 
divided  close  to  their  points  of  origin,  and  I  do  not  hesitate  to  include  the  large 
veins  in  the  same  ligature  in  order  to  saye  time.  With  the  vessels  I  have  men- 
tioned quickly  secured,  there  is  really  no  necessity  for  even  temporarily  loosening 
the  tourniquet.  If  the  operator  is  not  sure  that  he  has  found  and  securely  placed 
the  ligatures  upon  these  larger  vessels,  it  is  a  simple  matter  to  loosen  slowly  the 
grasp  of  the  tourniquet  until  the  pulsation  of  the  larger  trunks  is  perceptil^le. 
No  attention  should  be  paid  to  the  general  oozing  from  the  large  muscular  sur- 
faces which  have  been  divided.  If  every  oozing  point  were  ligatured,  from  half 
an  hour  to  an  hour  would  be  consumed  in  securing  a  dry  wound  in  the  majority 


Fig.  137. — Section  through  left  thigh  in  the  upper  third.     1 ,  Superficial  femoral  artery,  vein,  and  saphe- 
nous nerve.     2,  Deep  femoral  vessels;  near-by  the  obturator  nerve  and  vessels.     3,  Sciatic  nerve 


of  instances.  In  order  to  hasten  the  operation  and  stop  the  oozing,  I  introduce 
a  snug  packing  of  sterile  iodoform  gauze  ribbon  into  the  cavity  of  the  acetabulum 
and  the  space  between  the  muscles  from  which  the  bone  has  been  removed,  leaving 
one  end  of  the  ribbon  to  jjass  out  between  the  flaps  for  the  purpose  of  its  removal. 
With  a  long,  half-curved  Hagedorn  needle,  armed  with  good-sized  catgut,  deep 
sutures  are  passed  through  the  stumps  of  the  divided  muscles  in  such  a  way  that 


82 


AMPUTATIONS 


large  masses  of  muscle  are  brought  tightly  together  when  these  sutures  are  tied, 
taking  two  or  three  inches  into  the  grasp  of  each  suture.  The  needle  is  not 
passed  in  the  proximity  of  the  large  vessels  or  the  sciatic  nerve.  This  effectively 
and  rapidly  controls  all  oozing.  Nothing  remains  but  to  close  the  flap  with  silk- 
worm-gut sutures,  dry  and  cleanse  it  off  thoroughly,  seal  it  with  collodion  in  its 
entire  extent  to  prevent  any  infection  from  the  genital  or  anal  region,  apply  a 
large,  loose  dressing  of  iodoform  and  then  sterile  gauze,  and  a  tight  bandage  over 
the  first  light  dressing.  The  pins  are  then  removed  and  the  remainder  of  the 
dressing  completed.  Preliminary  pressure  of  the  light  dressing  prevents  oozing 
and  the  wound  remains  dry. 

When,  from  destruction  of  the  parts,  by  accident  or  disease,  or  by  the  prox- 
imity of  a  neoplasm,  this  ideal  method  is  not  practicable,  any  modification  may 


Pig.  138. — Transverse  section  of  left  tliiyh  lliiougli  )e.■j^;er  triicliaiiter.  Looking  from  below  upward.  1, 
Saphenous  vein.  2,  Superficial  femoral  vein  and  artery.  3,  Profunda  femoral  vein  and  arterj', 
anterior  crural  nerve  between  the  two  arteries.  4,  Obturator  nerve  and  artery.  5,  Sciatic  nerve 
and  artery. 


be  employed,  preference  being  given  to  the  incision  which  keeps  farthest  from 
the  tumor  and  gives  the  healthiest  flaps.  When  there  is  not  sufficient  material 
to  cover  the  stump,  it  is  even  safer  to  err  on  the  side  of  an  unclosed  wound  and' 
trust  to  granulation  or  grafting  for  ultimate  closure. 

In  the  first  two  operations  I  did,  I  divided  the  femur  on  a  line  with  the 
incision  through  the  muscles,  tying  the  vessels,  removing  tlie  tourniquet,  and  then 
dissecting  out  the  upper  fragment  of  the  femur.  I  found  it  exceedingly  difficult 
to  disarticulate  the  head  of  the  bone,  and,  at  the  suggestion  of  the  late  Dr.  J.  B. 


AMPUTATIONS 


83 


Murdock,  of  Pittsburg,  Pa.,  who  witnessed  the  operation,   I  have  since  left  the 
femur  intact  in  order  to  facilitate  the  disarticulation.'^ 


Fig.  139. — Section  through  the  left  hip  Lookinf;  trom  below  upward.  Reduced  from  life  size.  1, 
Femoral  \  ein,  artery  and  crural  ner^  e  m  order  from  within  outward.  2,  Great  sciatic  nerve,  artery, 
and  vein.     3,  Epiga-stric  vein.     4,  Vessels  to  acetabulum. 


1  During  the  Civil  War  of  the  United  States  (1861-1865)  the  death-rate  from  amputation  at 
the  hip-joint,  following  gunshot  wounds  was  ninety-three  per  cent. 

Dr.  John  F.  Erdmann,  in  the  "Annals  of  Surgery,"  September,  1895,  says  that  from  January, 
1884,  to  January,  1895,  there  were  eighteen  hip-joint  amputations  done  in  Bellevue,  Roosevelt, 
St.  Luke's,  Mount  Sinai,  Chambers  Street,  German,  and  Presbyterian  Hospitals,  with  eight  deaths, 
a  mortality  of  44.4  per  cent.  If  from  this  list  are  eliminated  seven  cases  done  by  my  method — 
all  of  which  recovered — it  leaves  the  mortality  ratio  by  other  methods  in  the  hospitals  of  New 
York  72.7  per  cent. 

I  would  not  imply  that  such  a  death-rate  as  this  would  follow  any  other  method  of  operation, 

for  I  know  that  in  the  hands  of  careful  and  thorough  operators  much  better  results  would  follow. 

In  a  large  number  of  oases  tabulated  by  the  author  in  which  his  method  of  haemostasis  was 

employed,  the  ratio  of  mortality  after  hip-joint  amputation  on  account  of  disease  did  not  exceed 

eight  per  cent. 

In  an  emergency  a  single  pin  may  stiffice  (Dr.  Emory  Lanphear),  and  large  mattress  needles 
or  pins  extemporized  from  telegraph  wire  may  be  substituted  (Dr.  George  Emerson  Brewer). 

In  a  ease  where  the  pins  were  not  available,  Dr.  John  B.  Deaver  held  the  rubber-tube  tourniquet 
in  place  by  passing  a  loop  of  bandage  around  the  tubing  in  front  and  behind  and  making  upward 
traction  to  prevent  slipping  when  the  disarticulation  was  made. 

The  condition  will  be  exceedingly  rare  when  the  performance  of  abdominal  section  in  order 
to  make  digital  compression  of  the  common  iliac  to  prevent  htemorrhage  in  amputation  at  the  hip, 
as  suggested  by  Dr.  Charles  ^McBurney,  will  be  justifiable. 

With  the  pins  and  tubing,  complete  hsmostasis  has  been  secured  in  every  instance,  and  the 
cases  now  reported  run  into  the  hundreds.  The  disarticulation  may  be  done  in  five  minutes  and 
the  entire  operation  be  completed  in  three  quarters  of  an  hour. 

Of  this  method.  Prof.  W.  W.  Keen,  reporting  one  of  his  successful  cases,  said:  "It  was  reserved 
for  an  American  surgeon  to  devise  what  is  undoubtedly  the  best  method,  and  in  fact  which  I  think 
we  can  now  call  the  only  method,  of  hsemostasis  in  amputation  at  the  hip-joint." 


CHAPTEE    VI 

THE    LYMPHATIC    VESSELS    AND    GLANDS,    THE    VEINS    AND    ARTERIES 

Lymphangitis.  Phlebitis.  Arteritis.  ,  Adenitis.  Vascular  Tumors.  Treatment  by  the  Injec- 
tion of  Boiling  Water.  Varicose  Veins.  Mayo's  Operation.  Babcock's  Procedure  Modi- 
fied.    Excision. 

The  pathology  of  the  Ijanjihatics  closely  reseml)les  that  of  the  veins  with  which 
they  are  intimately  associated.  One  difference  of  great  significance  is  that  the 
lymjDhatic  vessels  in  many  portions  of  the  body  are  closed  tubes,  for  at  varying 
intervals  in  their  route  to  pour  their  contents  into  the  veins  each  trunk  breaks  up 
into  smaller  branches,  ending  in  blind  capillaries  in  the  substance  of  a  lymphatic 
gland.  (It  is  held  that  there  is  no  direct  communication  between  the  afferent  and 
efferent  vessels  in  these  glands.)  It  follows  that  where  this  arrangement  prevails 
infectious  material  in  the  lymph  current  cannot  rapidly  enter  the  systemic  circu- 
lation. These  glands  may  be  compared  to  breastworks,  behind  which  the  leuco- 
cytes rally  for  the  defense  of  the  tissues.  In  the  lymphatic  channels,  near  the 
vault  of  the  diaphragm  and  with  the  veins,  there  are  no  obstacles  to  direct  systemic 
infection. 

Lympliangiiis  implies  an  infection  of  all  the  structures  of  the  wall  of  a  lymph- 
carrying  vessel.^    Hyperemia  and  cell  proliferation  occur,  and  there  may  be  coagu- 
lation of  lymph  with  occlusion  of  the  ducts.     Should  the  infecting  organisms  be  ' 
pyogenic,  suppuration  follows,  or  the  inflammatory  process  may  be  non-suppurative 
as  in  erysipelas. 

Symptoms. — Following  the  inoculation  iipon  an  abrasion  of  any  septic  organ- 
ism, there  is  within  a  few  hours  a  painful  sense  of  throbbing  and  burning  in  the 
wound,  usually  proportionate  to  the  rapiditj'  of  swelling.  In  from  ten  to  twentj^- 
four  hours  the  redness,  locally  and  along  the  lymphatics  leading  toward  the  center, 
may  be  recognized.  While  the  outline  of  the  injected  vessels  can  rarely  be  made 
out  by  palpation,  there  is  none  the  less  z,  thickening  in  the  tissues  of  the  vessel 
wall,  and  often  in  the  perivascular  tissues.  In  these  pain  is  present  in  a  fair 
proportion  of  cases,  while  in  others  it  cannot  be  elicited  even  by  direct  pressure. 
The  same  is  true  of  the  nearest  lymphatic  glands,  which  by  palpation  are  easily 
recognized. 

The  febrile  movement,  which  usually  begins  within  twenty-four  hours  after 
infection,  is  generallj^  introduced  by  a  chill  or  a  series  of  chilly  sensations.  In  the 
progress  of  the  infection  the  temperature  may  rise  rapidly.  Nausea,  vomiting, 
delirium,  and  the  train  of  symptoms  which  accompany  septicsmia  may  follow. 
If,  however,  the  conditions  are  unfavorable  to  the  progress  of  the  disease — that  is, 
if  the  resistance  of  the  tissues  is  approximately  normal — the  temperature  gradually 
declines  with  the  destruction  of  the  invading  organs  by  the  leucocytes,  and  the 
symf)toms  of  infection  disappear. 

In  the  differentiation  of  lympliangiiis  from  phlehitis  it  is  well  to  bear  in  mind 
that  in  the  latter  the  lines  of  discoloration  are  wider  and  follow  the  track  of  well- 
known  and  appreciable  veins,  and  that  in  general  these  veins  are  very  painful  to 
pressure. 

The  treatment  of  acute  lymphangitis  is  local  and  general.  Immediate  free  in- 
cision of  the  infected  focus  is  imperative.  This  can  be  done  painlessly  by  local 
aneesthesia  with  cocaine,  or  general  narcosis  with  nitrous-oxide  gas.  In  cocaine 
infiltration  (for  example,  in  finger  infection)   the  needle  should  be  entered  at  a 

84 


THE   LYMPHATIC   VESSELS  AND   GLANDS,   THE   VEINS  AND   ARTERIES       85 

jjoint  slightly  removed  from  the  infected  and  jDainful  area,  and  anaesthesia  effected 
by  carefnl  approaches  to  the  line  of  incision.  Should  this  be  through  the  palmar 
surface,  which  is  normally  hypersensitive,  the  needle  should  he  entered  on  the 
dorsum  of  the  finger  and  carried  just  beneath  the  skin  to  be  incised.  A  moist 
bichloride  dressing  (1-3000),  or  an  antiseptic  flaxseed  or  other  poultice,  should 
be  applied.^ 

If  incision  has  been  delayed,  or  if  infection  is  traveling  along  the  lymphatics, 
every  point  of  induration  should  also  be  freely  incised  not  only  to  permit  the 
escape  of  septic  matter,  but  to  relieve  tension  and  prevent  sloughing.  These  in- 
cisions should  be  treated  as  just  advised. 

With  the  first  symptoms  of  infection  the  bowels  should  be  emptied  by  calomel 
triturets  (grains  3  "to  5  in  one  dose),  to  be  followed  in  six  or  eight  hours  by  castor 
oil  or  salts.     Eest  in  bed,  nutritious  diet,  and  fresh  air  are  essential. 

The  process  of  repair  in  wounds  of  the  lymphatic  vessels  does  not  differ  essen- 
tially from  that  in  the  veins.  It  has  been  demonstrated  that  lymph  and  chyle  may 
be  carried  into  the  veins  by  collateral  circulation  after  occlusion  of  the  larger 
vessels,  even  of  the  thoracic  duct. 

Varicosities  maj^  occur  in  these  vessels,  as  in  the  veins.  In  some  instances  cystic 
dilatations  occur,  most  frequently  in  the  tongue,  lips,  and  about  the  neck.  These 
are  sometimes  congenital.  In  their  structure  they  are  trabeculated,  the  caverns 
being  filled  with  lymph. 

'New  formations  of  lymphatic  vessels  are  occasionally  met  with  (lympho-angei- 
oma).  The  treatment  of  varicosities  does  not  differ  from  that  advised  for  the  same 
lesions  of  the  veins.  Lymphatic  new  growths  may  be  dealt  with  as  advised  in 
the  treatment  of  angeiomata. 

Adenitis. — In  acute  infection  of  a  lymphatic  gland  the  changes  in  its  structure 
are  very  rapid.  The  cells  of  the  reticulum  and  endothelia  proliferate,  and,  in  the 
presence  of  pyogenic  organisms  with  their  well-known  property  of  liquefaction, 
suppuration  rapidly  supervenes.  Necrosis  of  tissue  is  facilitated  by  the  great  pres- 
sure which  rapid  cell  proliferation  causes  within  the  non-elastic  capsule. 

The  local  symptoms  are  pain,  redness,  and  swelling.  The  general  symptoms 
are  as  given  in  lymphangitis.  If  incision  be  delayed,  the  infective  organisms  may 
pass  through  the  gland,  enter  the  efferent  vessels,  and  find  their  way  to  general 
vascular  system. 

The  treatment  of  ande  adenitis  should  be  the  same  as  that  given  in  Ijonphan- 
gitis.  Though  the  infection  be  seemingly  mild  in  character,  early  incision  in 
indicated. 

In  children,  cervical  adenitis  is  very  frequently  observed  when  suppuration  does 
not  ensue  and  when  tuberculous  infection  is  not  present.  In  these  cases  there  is 
a  mild  infection  from  a  catarrhal  pharyngitis  or  tonsilitis.  The  pyogenic  germs  are 
either  not  present  or,  being  present,  do  not  find  conditions  favorable  for  prolifera- 
tion. The  swelling  which  ensues  is  due  to  excitation  and  proliferation  of  the  nor- 
mal cells  of  the  gland.  This  form  of  adenitis  is  met  with  chiefly  in  cold  and 
damp  climates,  and  in  j-oung  subjects  who  are  improperly  fed  and  housed.  The 
enlarged  glands  are  very  slightly,  if  at  all,  painful,  and  there  is  at  first  little  or 
no  constitutional  disturbance.  The  symptoms  do  not  differ  very  widely  from  those 
of  incipient  tuberculous  adenitis,  3'et  before  advising  extirpation  the  mouth,  tonsils, 
and  nasopharynx  should  be  carefully  examined.  With  the  removal  of  adenoids  or 
tonsils  which  are  infected,  together  with  tonics,  proper  feeding,  and  improved 
hygienic  surroundings,  these  lymphomata  very  frequently  disappear,  while  those 
caused  by  tuberculous  infection  persist. 

Tuberculous  adenitis  is  more  frequently  met  with  in  the  glands  of  the  neck 
beneath  the  jaw,  in  the  chain  of  lymphatics  following  the  deep  jugular  vein,  and 
along  the  upper  posterior  border  of  the  mastoideus  muscle.  The  bacilli  find  their 
way  into  the  lymphatic  channels  through  abrasions  of  the  buccal  wall  or  alveolus, 
and  more  frequently  from  foci  of  infection  in  the  tonsil.  Eeaching  the  substance 
of  the  nearest  gland,  their  progress  is  temporarily  arrested,  and  here  they  undergo 

'  This  poultice  is  made  by  mixing  flaxseed  in  warm  mercuric-chloride  solution  (1-3000). 


86       THE   LYMPHATIC   VESSELS  AND   GLANDS,   THE   VEINS   AND   ARTERIES 

a  more  or  less  rapid  proliferation.  There  res^ilts  an  inflammatory  process,  mild 
in  character,  unless  there  is  a  mixed  (pyogenic)  infection.  In  uncomplicated 
tubercular  infection  the  normal  cells  of  the  gland  also  undergo  proliferation — the 
so-called  lymphoid  cells.  The  pathogenic  organisms  in  the  deep  portions  of  the 
inflamed  area  continue  to  proliferate  until  the  capsule  of  the  gland  itself  is  reached. 
In  a  certain  proportion  of  cases  at  this  stage  the  nodules  undergo  caseous  or 
calcareous  degeneration,  and  the  bacilli  perish  without  spore  formation.  When, 
under  other  conditions,  the  spores  of  tuberculosis  are  developed,  these  may  lie  dor- 
mant for  a  varying  period  until,  under  conditions  again  favorable  to  their  prolifera- 
tion, a  fresh  outbreak  occurs  and  other  glands  in  the  chain  are  invaded.  In  most 
cases  of  tuberculous  adenitis  mixed  infection  occurs,  due  to  the  presence  of  ijyo- 
genic  micro-organisms,  and  suppuration  supervenes  with  all  the  symptoms  of  acute 
adenitis. 

The  chief  symptom  of  tuberculous  adenitis  is  a  gradual  and  persistent  enlarge- 
ment of  the  lymphatic  glands  leading  from  the  original  focus  of  infection.  Pain 
is  not  characteristic  of  these  enlargements  unless  pyogenic  infection  has  occurred. 
As  a  rule,  there  are  no  constitutional  symptoms  of  sepsis,  the  pulse  and  temperature 
remaining  normal.  When  the  disease  assumes  a  chronic  character,  and  a  number 
of  glands  are  involved,  the  processes  of  nutrition  are  seriously  disturbed. 

As  soon  as  the  diagnosis  of  tu1)erculous  adenitis  is  confirmed,  a  thorough  re- 
moval of  all  infected  glands  should  be  advised;  and  it  is  proper  to  state  that,  no 
matter  how  -thoroughly  the  operation  may  be  done,  a  revision  may  be  necessary, 
for  the  reason  that  the  infective  organisms  have  already  passed  into  the  efferent 
channels,  where  they  cannot  be  recognized  until  proliferation  is  present  in  other 
glands. 

The  adenitis  of  syphilis  will  be  considered  with  that  disease. 

In  addition  to  acute  and  tuberculous  adenitis,  there  is  a  condition  of  glandular 
enlargement  known  as  "  Hodgkin's  disease,"  and  another  form  of  malignant 
lymphoma  known  as  "  Billroth's  disease."  Clinically,  it  is  difficult  to  distinguish 
between  these  two  forms,  and  recent  authors  claim  that  they  are  practically  iden- 
tical with  lymphosarcoma.^ 

Adults  from  twelve  to  twenty-five  years  of  age  are  most  frequently  affected. 
The  glands  in  any  part  of  the  body  may  be  the  seat  of  lesions,  although  the  name 
of  Billroth  is  associated  more  particularly  with  lymphomata  of  the  neck.  The 
skin  becomes  pale  and  waxy,  the  spleen  enlarged,  and  lymphatic  metastases  occur 
in  the  lungs,  spleen,  liver,  and  other  organs.  The  red  blood  discs  are  greatly 
diminished  and  the  leucocytes  increased.  Pain  is  absent  unless  the  tumors  press 
upon  contiguous  organs.^ 

Phlebitis  means  an  inflammation  of  the  tissues  which  form  the  walls  of  a  vein. 
Endo-,  meso-,  and  peri-phlebitis  are  terms  used  to  designate  inflammation  involv- 
ing respectively  the  inner,  middle,  and  outer  layers  of  the  vessel  wall.  A  vein  is 
a  tubular  structure,  made  up  in  general  of  an  inner  layer  of  flat,  polygonal  cells 
{tunica  intima),  a  middle  layer  (media),  composed  chiefly  of  elastic  tissue,  and 
an  outer  layer  [externa),  containing  elastic  loops,  connective  tissue,  and  unstriped 
muscle.  The  vasa  vasorum  and  nerves  are  distributed  to  the  outer  and  middle 
tunics. 

The  changes  induced  are  first  noticed  in  the  two  outer  layers.  The  vasa  vaso- 
rum are  dilated,  the  leucocytes  appear  in  the  extravascular  spaces,  while  the  normal 
connective-tissue  cells  undergo  proliferation,  resulting  in  thickening  of  the  venous 

1  See  "N.  Y.  Med.  Jour.,"  March  30,  1907,  Dr.  W.  B.  Coley. 

2  An  exceedingly  rare  form  of  disease  of  the  lymphatics  is  that  caused  by  fUaria  (sanguinis 
homiriis).  The  presence  of  this  parasite  in  the  lymph  channels  often  leads  to  obstruction,  and 
from  the  parent  nest  a  crop  of  organisms  may  escape  into  the  blood  vessels.  In  the  blood  they  . 
are  rarely  detected  during  daylight,  but  if  a  specimen  be  examined  several  hours  after  dark,  they 
may  be  discovered.  The  filaria,  about  1-80  of  an  inch  in  length,  is  constantly  in  motion.  In 
the  blood  they  do  not  produce  any  particular  disturbance,  but  those  which  lodge  in  the  Ijrmph 
ducts  cause  connective-tissue  hyperplasia  and  swelling  (elephantiasis).  There  is  as  yet  no  known 
method  of  relieving  the  body  of  these  parasites.  It  is  probable  that,  in  common  with  certain 
other  organisms  found  in  the  blood,  they  may  be  destroyed  by  a  prolonged  high  temperature,  as 
in  tjTJhoid  or  remittent  fever. 


THE   LYMPHATIC   VESSELS   AND   GLANDS,   THE   VEINS   AND   ARTERIES       87 

wall.  Should  the  infection  be  mild  in  character,  resolution  may  occur  without 
involvement  of  the  intima.  In  the  more  severe  types  of  phlebitis  the  lining  mem- 
brane is  involved,  thrombosis  results,  and  new  capillaries  protect  themselves  into 
the  coagulum. 

When  phlebitis  is  complicated  with  thrombosis  there  is  always  danger  that  the 
coagulum  may  be  carried  to  the  heart  and  lodged  in  the  pulmonary  arteries  with 
fatal  result.  Septic  organisms  passing  through  the  pulmonary  capillaries  enter  the 
systemic  circulation  and  produce  the  general  STOiptoms  of  septicaemia. 

Phlebitis  is  one  of  the  most  serious  of  the  surgical  diseases.  The  vessels  in- 
volved are  swollen,  tense,  and  less  elastic  than  normal.  They  may  be  traced  by  the 
dull  red  color  of  the  skin  immediately  over  the  diseased  vein.  Pain  is  constant, 
and  is  rendered  intense  by  pressure.  The  osdema  on  the  distal  side  of  the  lesion 
is  in  proportion  to  the  obstruction  to  the  return  circulation  and  the  infiltration 
of  the  perivascular  tissues.  The  febrile  movement  varies  with  the  virulence  of 
the  infection  and  the  rapidity  of  its  progress. 

Treatment. — Complete  rest  is  the  first  essential.  Manipulation  or  movement 
is  dangerous,  not  only  because  it  exaggerates  the  inflammatory  process,  but  may 
possibly  cause  the  dislodgment  of  thrombi.  With  the  first  suggestion  of  pus  for- 
mation, or  when  cedema  is  extensive,  free  incisions  parallel  with  the  veins  should 
be  made.  These  wounds  should  be  treated  by  the  open  method,  applying  a  moist 
1-5000  bichloride  dressing,  with  warm  irrigations  at  intervals,  until  the  symptoms 
have  disappeared.  Careful  attention  to  the  alimentary  canal,  nutritious  diet,  mild 
stimulation,  and  a  free  supply  of  pure  air  will  complete  the  constitutional  treatment. 

Arteritis  is  an  inflammatory  process  which  involves  the  entire  thickness  of  the 
arterial  wall.  When  the  intima  is  alone  involved,  it  is  designated  endarteritis;  the 
outer  coat,  periarteritis;  the  middle  coat,  mesarteritis. 

Arteritis  may  be  a  local  or  general  disease,  and  of  traumatic  or  idiopathic  origin. 
Simple  endarteritis  is  more  frequently  met  with  in  the  aorta  and  other  large  arteries 
near  the  heart.  It  may  be  caused  by  sj'philis,  rheumatism,  gout,  alcoholism,  chronic 
nephritis,  or  any  chronic  morbid  process  which  poisons  the  blood  and  impairs  its 
nutritive  qualities. 

The  sequelae  of  arteritis  may  be  fatty  degeneration,  atheroma,  calcification,  par- 
tial or  complete  occlusion,  or  dilatation  (aneurism). 

Though  not  as  frequent  as  in  phlebitis,  thromhosis  and  embolism  often  result 
from  arteritis. 

Vascular  Tumors 

Vascular  new  formations  {angeiomata)  may  be  considered  clinically  under  three 
heads : 

1.  Arterial  angeioma  (cirsoid  aneurism).  2.  Capillary  angeioma  (mother's 
mark).     3.  Venous  angeioma  (cavernous  njevus). 

In  arterial  angeioma  there  is  an  elongation  and  dilatation  of  the  terminal  arte- 
rioles. A  single  vessel  may  be  affected  or  several  arterioles  of  a  given  area  may 
be  involved.  It  is  most  frequently  observed  upon  the  scalp,  the  neck,  and  the 
hands,  and  may  be  congenital  or  acquired. 

On  accou.nt  of  haemorrhage,  it  has  been  found  impossible  to  remove  them  by 
dissection,  and  ligation  of  the  arteries  leading  into  the  tumors  has  almost  without 
exception  failed  to  be  of  benefit. 

In  1901  the  author  devised  a  method  of  treatment  for  these  neoplasms  which 
has  proved  successful  in  every  instance  in  which  it  has  been  employed.  The  tech- 
nic  is  given  in  the  following  history:  Miss  S.  C,  aged  twent3--seven.  In  1885,  in 
her  tenth  year,  she  noticed  a  small  pulsating  tumor  in  the  temporal  artery  above 
the  ear.  This  was  tied,  but  without  benefit.  Two  years,  and  again  five  years,  later 
attempts  were  made  to  strangulate  the  mass  by  subcutaneous  ligatures,  but  without 
success.  Twelve  years  later  there  was  a  large  pulsating  mass  covering  one  half  of 
the  left  side  of  the  scalp,  which  measured  five  by  six  inches,  and  was  elevated  above 
the  level  of  the  normal  scalp  from  one  half  to  one  inch. 

Leading  into  the  tumor  were  five  arteries  much  larger  than  normal — two  from 
the  left  temporal,  one  from  the  right  temporal,  and  one  from  each  occipital  trunk. 


88       THE   LYMPHATIC   VESSELS  AND   GLANDS,   THE   VEINS   AND   ARTERIES 

The  author's  nietal  syringe  (Fig.  140),  taken  from  the  boiler,  was  immediately 
filled  with  boiling  water.  With  the  hands  protected  by  two  pairs  of  heavy  gloves, 
the  needle  was  entered  along  the  course  of  the  arteries  leading  into  the  mass  two 
inches  from  the  tumor,  and  fifteen  or  twenty  minims  of  boiling  water  were  in- 
jected at  each  point,  causing  an  immediate  arrest  of  pulsation  in  these  vessels. 
The  long  needle  was  then  thrust  from  one  side  of  the  tumor  to  near  the  opposite 
surface,  and  about  a  dram  of  hot  water  forced  out.  Withdrawing  the  needle, 
for  every  half-inch  this  was  repeated.  It  was  then  reentered  one  half  inch 
from  the  first  line  of  injection,  and  this  was  repeated  until  the  entire  mass 
was  consolidated.  About  five  ounces  of  boiling  water  were  used.  No  reaction 
followed.  There  was  no  pain,  l)ut  a  very  considerable  oedema  of  the  scalp  and 
face  developed. 

Despite  the  high  temperature  of  the  water  and  the  thorough  subcutaneous  coag- 
ulation, there  was  no  sloughing  of  the. scalp.  More  than  five  years  have  elapsed; 
there  has  been  no  return  of  the  growth,  and  the  patient  is  entirely  cured. 

Venous  angeioma  (cavernous  nipvus)  is  much  more  frequently  met  with  than 
cirsoid  aneurism.  I  have  treated  a  large  number  of  these  tumors  by  the  injection 
of  boiling  water,  so  far  without  accident,  and  with  a  cure  in  every  instance. 

C.  G.,  a  well-developed  child  nine  years  old.  At  birth  there  was  a  "mother's 
mark,"  or  blue  spot  about  as  large  as  a  quarter  of  a  dollar,  on  the  back  just  above 
the  right  shoulder.  At  the  age  of  two  years  it  began  to  grow  perceptibly.  In  the 
fifth  year,  when  the  tumor  was  about  seven  inches  in  length  and  half  as  wide,  an 
effort   was   made   to   remove  it  by  operation,  but  was  abandoned   on  account   of 


Fig.   140. — The  author's  all-metal  syringe  for  injecting  hot  water. 

haemorrhage.  A  year  and  a  half  later  a  second  attempt  was  made,  and  again 
abandoned.  When  she  came  under  my  observation  (February,  1902)  there  was  a 
large  venous  angeioma  occupying  the  back  from  the  edge  of  the  trapezius  muscle, 
above  the  right  shoulder,  reaching  to  the  middle  line  between  the  two  scapula, 
extending  downward  as  far  as  the  twelfth  rib  and  well  over  to  the  right  side.  The 
surface  of  the  mass  was  from  one  and  a  half  to  two  inches  above  the  level  of  the 
body.  To  the  touch  it  was  soft  and  compressible,  the  venous  channels  remaining 
empty  under  pressure  and  refilling  as  soon  as  this  was  removed. 

Under  ether  narcosis  the  Ijoiling-water  injections  were  made  as  in  the  former 
operation,  a  very  long  needle  being  carried  erossways  through  the  tumor  at  eleven. 
difFerent  points.  The  child  complained  of  no  pain  after  consciousness  was  restored, 
and  there  was  no  elevation  of  temperature.  Coagulation  seemed  to  be  perfect 
throughout.  Seven  months  later  the  entire  growth  had  disappeared,  with  the 
exception  of  a  rounded  mass  about  three  inches  in  diameter,  which  is  shown 
in  the  center  of  the  area  of  the  accompanying  illustration  (Fig.  141).  This 
was  then  treated  in  the  same  way.  Five  years  have  elapsed  and  the  patient  is 
entirely  cured.     For  these  larger  tumors  a  larger  instrument  may  be  employed. 

In  1907  I  operated  upon  a  large  venous  angeioma  which  occupied  the  left  side 
of  the  neck  below  the  angle  of  the  jaw.  It  involved  the  external  and  deep  jugular 
veins,  and  the  tumor  measured  three  by  four  inches  and  projected  outward  about 
two  inches  beyond  the  level  of  the  neck.  For  fear  that  the  hot  water  might  produce 
embolism  in  the  deep  jugular  or  internal  carotid,  in  either  of  which  a  fatal  issue 
would  result,  I  attempted  to  extirpate  the  mass  by  dissection.  Extensive  coils  of 
large  veins  were  soon  encountered  with  such  profuse  bleeding  that  compression  had 
to  be  employed  and  the  operation  abandoned.  A  week  later  a  separate  temporary 
ligature  was  thrown  around  the  common  carotid  artery  and  the  internal  jugular 


THE   LYMPHATIC   \T:SSELS   .^NTD   GL.OCDS,   THE   VEINS   .\^'D   ARTERIES       S9 


vein  just  above  the  clavicle,  and  then  were  twisted  and  held  with  forceps,  com- 
pletely shutting  off,  for  the  time  being,  the  circulation  in  both.  By  this  procedure 
not  only  was  the  blood  in  the  vein  held  stagnant  and  dammed  back,  h}-perdistending 
the  coils  in  the  tumor,  but  at  the  same  time  the 
ligattire  of  the  common  carotid,  the  tightening  of 
which  was  synchronous  with  a  pinhole  contraction 
of  the  pupil  of  that  side,  caused  reversal  of  the  cur- 
rent in  the  internal  carotid  by  reason  of  the  free 
anastomosis  through  the  circle  of  Willis  with,  and 
the  increased  supply  from,  the  artery  of  the  oppo- 
site side. 


Fig.  141. — Case  of  C.  G.,  extensive 
cavernous  n£e^■us  of  the  back, 
after  the  second  injection. 


Fig.  142. — Inoperable  ven- 
ous angeioma,  before  in- 
jection. 


Fig.  143. — The  same,  one  year 
later. 


Xo  coagula  could  now  reach  the  heart  or  brain,  and.  superficially  occluding  the 
external  jugular  by  digital  pressure,  the  entire  mass  was  solidified  by  the  careful 
instillation  of  boiling  water.  Every  effort  was  made  to  keep  the  heat  as  far  as 
possible  from  the  pneumogastric,  facial,  and  other  contiguous  nerves.  After  fifteen 
or  twenty  minutes,  there  being  no  evidence  of  coagulation  in  the  vein  at  the  seat 
of  ligature,  the  ligature  on  the  internal,  and  the  compression  of  the  external, 
jugular  were  removed.  The  common  carotid  was  next  unlocked,  and  the  circu- 
lation in  that  side  of  the  brain  restored,  as  shoAvn  by  the  immediate  dilatation  of 
the  pupil.  Within  two  months  the  solidified  mass  had  entirely  disappeared,  and 
the  patient,  a  lad  of  nineteen  years,  is  well.  The  growth  was  congenital,  but  had 
grown  rapidly  within  the  last  few  years. 

In  the  use  of  an  agent  so  capable  of  doing  harm  every  precaution  shoitld  be 
taken  to  prevent  scalding.  Water  so  hot  that  a  single  drop  falling  on  the  skin 
will  destroy  the  epidermis,  when  iajected  under  the  skin  will  coagulate  the  blood 
without  injury  to  the  integument.  Wliile  the  boiling  point  (213°  F.)  is  not 
always  necessary,  not  infrequently,  in  order  to  maintain  the  proper  temperature, 
an  alcohol  lamp  should  be  held  under  the  barrel  of  the  syringe.  All  parts  of  the 
patient's  body  near  the  field  of  operation  should  be  protected  from  scalding  by 
thick  layers  of  towels  or  gauze.  A  mass  of  gauze  should  be  kept  below  the  needle 
point,  which,  at  the  proper  moment,  is  thrust  through  the  gauze  into  the  tumor. 
An  assistant  should  be  immediately  at  hand  with  a  sponge  saturated  in  cold 
water,  so  that  in  case  of  an  unexpected  leakage  the  cold  can  be  instantly  applied 
and  prevent  scalding.  The  operator  should  be  careful  to  hold  the  iustrument 
beneath  his  hand  in  order  to  be  out  of  the  way  of  any  leakage.  While  so  far 
no  accident  has  occurred,  it  is  well  to  bear  ia  mind,  and  to  explain  to  patients 
subjected  to  this  procedure,  the  danger,  however  remote,  of  embolism. 

When  the  ttunor  is  located  upon  an  extremit}',  this  danger  can  be  obviated  by 
the  application  of  a  tourniquet  on  the  proximal  side,  which  should  not  be  removed 
until  coagulation  has  been  assured.  In  all  cases  firm  compression  should  be 
made  upon  any  vein  between  the  tumor  and  the  heart  until  the  mass  is  solidified. 
This  method  should  never  be  employed  where  an  important  nerve  trunk  may  be 
injured  by  the  heat. 

Capillary  angeiomata  are  verj*  much  more  often  met  with  than  either  of 
the  two  varieties  above  given.     They  are  frequently  congenital,  but  may  be  ac- 


90       THE   LYMPHATIC   VESSELS  AND   GLANDS,   THE   VEINS   AND  ARTERIES 

quired.  The}'  may  apiDear  as  reddish  or  blue  stains  or  injections  beneath  the 
normal  epidermis,  or  as  strawberrylike  elevations  without  an  epidermal  covering. 
Thev  are  usually  seen  on  the  face,  a  favorite  location  being  the  muco-cutaneous 
borders  of  the  lips,  the  wing  of  the  nose,  the  eyelid,  and  upon  the  forehead.  Their 
tendency  is  to  enlarge  until  puberty  when,  as  a  rule,  they  remain  stationary.  I 
have  treated  a  large  number  of  these  neoplasms  by  the  hot-water  injections,  a  very 
delicate  needle  and  a  small  syringe  being  employed.  More  than  ordinary  precau- 
tions are  necessary  on  account  of  the  importance  of  protecting  the  face.  Only 
a  few  minims  are  injected  at  any  one  point.  It  is  best  to  proceed  slowly  and  note 
the  changes  which  are  produced.  As  a  whole,  the  results  are  not  so  satisfactory 
as  in  the  treatment  of  cirsoid  aneurism  and  cavernous  n£e^^IS.  The  majority  of 
capillary  tumors,  not  being  protected  by  a  normal  epidermis,  break  down  under 
the  hot  water  and  become  infected.  Some  of  these  have  been  cured,  while  others 
have  been  markedly  reduced  in  size. 

Closely  related  to  the  more  suijerficial  forms  of  vascular  tumor  are  the  abnor- 
mal, circumscribed  hypertrophies  of  the  skin,  Icaown  as  moles,  which  may  be 
congenital  or  acquired.  They  may  occupy  any  jDortion  of  the  skin,  but  are  usually 
found  on  exposed  surfaces,  as  the  face,  neck,  and  hands.  The  most  frequent 
variety  is  that  which  appears  as  a  simple  elevation  from  which  a  few  stifE  hairs 
grow.  As  a  rule,  they  are  not  stained  with  pigment.  Wliile  benign  in  character 
as  a  result  of  irritation,  these  neoplasms  may  become  infected,  or  even  develop  into 
malignant  growths. 

Ncevus  pigmentosus  is  characterized  by  an  extensive  deposit  of  pigment  in  and 
immediately  beneath  the  epidermis,  in  color  varying  from  slate-gray  to  purple, 
mahogany,  or  wine-color,  and  at  times  extending  over  a  large  area.  The  lobule 
of  the  ear  and  the  integument  between  the  eyes  and  over  the  temple  is  a  common 
location.     It  is  sometimes  called  "  port-tuine  mar'k." 

Treatment. — When  the  pigment  area  is  so  small  that  it  can  be  excised  and 
the  edges  of  the  wound  brought  together  by  carefully  adjusted  sutures  without 
too  great  tension,  this  may  be  done.  When  a  muco-cutaneous  border  is  not  in- 
volved, transplantation  of  skin  is  indicated  when  after  excision  apposition  cannot 
be  secured.  Moles,  papillomata,  etc.,  should  also  be  excised.  These  operations 
can  be  done  painlessly  with  cocaine  anffisthesia.  The  smallest  curved  round  needles 
and  the  finest  silk  or  linen  should  be  used  when  union  by  suture  is  necessary. 
Small  incisions  may  be  maintained  in  apposition  without  suturing  by  coveriag 
with  collodion,  pressing  the  edges  together  until  the  collodion  sets. 

Venous  varix  consists  of  a  dilatation  and  elongation  of  the  veins.  It  may  in- 
volve the  deep  as  well  as  the  suj^erficial  veins,  but  those  immediately  beneath  the 
skin  are  most  seriously  affected.  Varicosities  are  especially  prone  to  occur  in  the 
superficial  veins  of  the  lower  extremities  (saphenous).  Hsemorrhoids  and  vari- 
coceles are  common  forms  of  varix.  Unusual  types  are  dilatation  of  the  jugulars, 
due  to  stenosis  of  the  vena  cava  descendens,  and  that  of  the  superficial  abdominal 
veins  from  stenosis  of  the  ascending  cava.  While  a  chain  of  veins  is  usually 
involved  a  limited  portion  of  a  single  vessel  may  be  the  seat  of  varix.  This  form 
is  due  to  paralysis  of  the  musculao-  tissue  in  the  walls  either  from  atrojjhy  or 
from  interference  with  the  function  of  the  nervi  vasorum. 

Poorly  fed  individuals,  especially  those  who  work  in  the  standing  posture,  are 
more  frequently  affected.  Pregnant  women,  multipara,  and  persons  suffering  from 
large  abdominal  tumors  or  any  interference  with  the  venous  return  through  the 
ascending  cava,  are  apt  to  develop  varicose  veius  in  the  legs. 

Occlusion  of  the  popliteal  vein  or  of  the  femoral  below  the  entrance  of  the 
internal  saphena  will  also  produce  a  varicose  condition  in  the  veins  of  the  leg 
and  lower  thigh.  This  condition,  however,  is  entirely  compensatory  and  not  oper- 
ative, as  it  differs  from  the  ordinary  varicose  veins  of  the  lower  extremity,  which 
are  due  to  diminished  resistance  in,  and  dilatations  of  the  walls  of,  these  vessels. 

In  well-marked  varix  the  veins  are  increased  in  caliber  and  in  length,  being 
coiled  and  twisted  upon  themselves  in  knotted  masses.  They  are  narrowed  in 
caliber  at  frequent  intervals,  opening  into  exjjanded  pouches,  in  appearance  not 
unlike  the  sacculated  large  intestine.     As  the  result  of  dilatation  the  valves  are 


THE   LYMPHATIC   VESSELS   AND   GLANDS,   THE   VEINS   AND   ARTERIES       91 

wholly  inefficient,  the  walls  are  weakened,  and  rupture  ma.y  occur.  Calcareous 
deposits  are  occasionally  met  with  in  the  vessel  walls,  while  the  lumen  is  not 
infrequently  occluded  by  thrombi. 

As  the  result  of  injury,  blood  stasis,  or  the  low  resistance  which  results  from 
impaired  nutrition,  inflammation  (phlebitis)  frequently  occurs  as  a  complication 
of  varLx.  One  of  the  greatest  dangers,  however,  from  varicosities  when  thrombi 
form  is  the  not  infrequent  dislodgment  of  a  clot,  which  is  rapidly  carried  with 
the  venous  current  to  the  heart  and  into  the  lungs  (embolism);  causing  obstruc- 
tion of  a  terminal  artery  or  larger  trunk,  and,  not  infrequentl)',  sudden  death. 
Many  cases  of  so-called  deaths  from "  heart  failure  result  from  this  form  of  em- 
bolism. When  phlebitis  or  thrombosis  and  embolism  do  not  occur,  ulcers,  espe- 
cially along  the  anterior  surface  of  the  leg,  are  very  common  complications  of 
varicose  veins. 

Treatvient. — The  treatment  is  j)alliative  and  operative.  In  the  early  develop- 
ment of  a  varicosity  mechanical  support,  carefully  and  jDcrsistentlj^  applied,  may 
arrest  the  progress  of  dilatation  and  render  operation  unnecessary.  For  the  lower 
extremity  an  elastic  stocking,  preferably  of  silk,  or  of  some  soft  material,  affords 
great  relief.  The  tension  in  the  rubber  should  be  no  more  than  is  necessary  to 
support  the  veins.  When  the  stocking  cannot  be  had,  Martin's  rubber  bandage  is 
a  fair  substitute.  The  chief  objection  to  any  apparatus  of  this  kind  is  the  dis- 
comfort experienced  in  warm  weather  from  perspiration.  No  matter  what  me- 
chanical device  is  adopted,  great  comfort  will  be  derived  from  the  relief  of  intra- 
abdominal pressure  by  free  evacuation  of  the  bowels.  When  occlusion  of  the 
popliteal  or  femoral  vein  has  occurred,  reliance  must  be  had  solely  upon  elastic 
compression,  since  gangrene  would  almost  inevitably  follow  excision  of  the  super- 
ficial veins.  In  the  earlier  development  of  varicosities  due  to  other  causes  they 
can  be  readily  and  safely  cured  by  excision  with  cocaine  angesthesia.  By  this  simple 
and  painless  procedure  prolonged  discomfort  and  remote  complications  may  be 
avoided.  In  delayed  cases  where  phlebitis  has  occurred,  infection  is  so  apt  to 
follow  surgical  intervention  that  the  strictest  aseptic  precautions  are  imperative. 

The  entire  extremity  in  the  field  of  operation,  and  well  beyond,  should  be 
thoroughly  shaved  and  scrubbed,  the  sebaceous  and  hair  follicles  rendered  sterile 
by  ether  and  alcohol,  and  the  limb  enveloped  in  a  1-3000  bichloride  dressing, 
preferably  for  twelve  hours  before  the  operation.  When  the  procedure  is  very 
extensive,  and  the  patient's  condition  will  tolerate  prolonged  narcosis,  this  should 
be  preferred,  with  nitrous  oxide  and  air  or  oxygen  as  the  anjesthetic.  Pneumonia  or 
nephritis  are  more  than  ordinarily  frequent  on  account  of  the  low  resistance 
in  these  subjects.  As  the  veins  are  not  easily  recognized  when  the  extremity  is  . 
emptied  of  blood  in  the  recumbent  posture,  it  is  advisable  to  compress  the  internal 
saphena  or  femoral  vein,  hyperdistend  the  varicosities  it  is  intended  to  excise,  and 
make  tracings  of  these  with  sterile  iodine  parallel  with,  and  one  half  of  an  inch 
away  from,  the  course  of  the  vessel. 

The  operative  treatment  consists  in  excision,  ablation,  or  multiple  ligature  of 
the  enlarged  vessels.  When  practicable,  one  of  the  methods  of  ablation  should 
be  selected.    The  following  ingenious  procedure  is  that  of  Dr.  C.  H.  Ma)'o: 

His  special  apparatus  consists  of  a  ring  vein  enucleator  (Fig.  144).  The  ring 
has  a  diameter  of  about  one  fourth  of  an  inch,  and  is  bent  upoir  the  tip  of  the 
shaft  at  an  angle  of  about  seventy  degrees.     The  saphena  vein  is  exposed  in  the 


Fig.   144. — C.  H.  Mayo's  vein  enucleator. 


upper  portion  of  the  thigh,  above  the  high  point  of  the  lesion,  the  proximal  end 
tied,  and  the  distal  section  clamped  an  inch  from  the  end,  which  is  passed  through  the 
ring  of  the  enucleator,  while  the  clamp  is  transferred  to  the  end  of  the  vein.  With 
the  vein  held  in  tension,  the  ring  is  forced  down,  tearing  ofE  the  lateral  branches 


92       THE   LYMPHATIC   VESSELS   AND   GLANDS,   THE   VELNS   AND   ARTERIES 

for  six  or  eight  inches.  An  incision  may  now  be  made  directly  over  the  end  of 
the  instrument,  the  stripped  vein  pulled  through,  and  the  procedure  repeated,  or, 
in  order  to  save  an  extra  wound,  the  vein  may  be  exposed  at  a  point  six  inches 
lower,  and  the  first  stejD  reversed  until  the  two  tunnels  meet,  when  the  entire  section 
of  at  least  twelve  inches  of  the  vessel  is  drawn  out  through  either  opening. 

During  this  operation  the  leg  is  held  in  an  elevated  position,  so  that  the  veins 
are  practically  emptied  and  the  bleeding  from  the  torn  lateral  branches  is  insig- 
nificant, and,  if  occurring,  ma}^  readily  be  controlled  by  direct  pressure.  As  soon 
as  the  vein  is  drawn  out  of  the  wound,  sterile  gauze  is  applied,  and  a  roller  ad- 
justed sufficiently  tight  to  compress  the  small  superficial  veins  and  arrest  htem- 
orrhage.  The  entire  extremity  should  be  covered  with  a  thin  layer  of  cotton  bat- 
ting, and  pressure  equalized  by  bandaging  from  tlie  toes  to  the  crotch. 

The  author  has  found  very  satisfactory  in  this  operation  the  emjDlojiuent  of 
the  ordinary  urethral  bulbous  bougies  used  for  locating  stricture.  The  method  is 
practically  that  of  Dr.  W.  Wayne  Babcock,^  with  tlie  exception  that  while  he  car- 
ries the  instrument  from  above  do"«Tiward,  the  author  inserts  the  instrument  laelow 
and  carries  it  iipward  so  as  not  to  meet  with  any  imjoediment  from  the  valves. 
Dr.  Babcock  recommends  a  longer  instrument  than  the  ordinary  urethral  bougie- 
a-boule. 

The  sajjhenous  vein  is  exposed  well  up  in  the  thigh,  clamped,  and  tied  with 
ten-day  catgut  one  half  of  an  inch  above  the  clamp  and  divided  between  the  ligature 
and  the  instrument. 

At  a  sufficient  distance  lower  down  to  suit  the  length  of  the  instrument  em- 
ployed, a  second  opening  is  made,  the  vein  exposed,  and  divided  between  two 
clamps.  Into  the  proximal  end  the  bougie  is  inserted  until  it  comes  in  contact 
witlr  the  forceps  at  the  first  incision.  A  silk  or  linen  thread  should  now  be  tied 
around  the  vein  just  behind  the  bulb,  after  which  the  instrument  is  drawn  down- 
ward, tearing  off  the  collateral  branches  and  bringing  the  vein  out  at  the  lower 
opening. 

When  the  traction  is  begun,  sterile  gauze  with  firm  compression  should  be  laid 
on  following  the  vein  as  it  is  torn  loose.  If  this  be  done,  and  a  roller  bandage 
at  once  applied,  no  extravasation  will  occur.  The  author  considers  this  a  very 
important  part  of  the  technic.  The  remaining  varicosities  may  be  treated  in  the 
same  manner. 

Neither  of  these  procedures  is  applicable  where  the  veins  are  greatly  enlarged 
and  very  tortuous  or  occluded  here  and  there  by  firm  thrombi,  or  where,  as  a 
result  of  phlebitis  strong  adhesions  have  formed.  Such  veins,  as  a  rule,  require 
the  open  incision,  removing  long  or  short  sections  as  may  be  necessary. 

As  heretofore  stated,  bleeding  may  be  controlled  by  elevating  the  foot,  which 
should  be  secured  by  a  bandage  to  a  steel  upright  attached  to  the  operating  table. 
Temporary  digital  compression  of  the  femoral  artery  will  soon  empty  the  ex- 
tremity in  this  position.  Should  hjemorrhage  prove  serious,  the  tourniquet  may 
be  employed.  Schaede's  oj)eration  of  circular  incision  of  the  leg  dividing  the 
skin  and  veins  (and  nerves)  down  to  the  deep  fascia  should  not  be  performed. 

Where  the  disease  is  limited  to  a  small  area,  a  simpler  procedure,  under  per- 
fectly satisfactory  cocaine  infiltration,  is,  through  a  very  small  incision,  to  tie  the 
main  efferent  vein  without  section  and  repeat  this  as  often  as  required,  no  two 
ligatures  being  nearer  than  two  inches.  After  the  incisions  are  closed  by  running 
ten-day  catgut  sutures,  and  each  incision  dried  out  by  pressure,  dry  sterile  gauze 
should  be  applied  with  cotton  over  this,  and  a  bandage  applied  from  the  toes  to 
the  crotch  with  firm  compression,  in  order  to  prevent  any  oozing  along  the  line 
of  the  excised  veins.  The  foot  and  leg  should  he  kept  elevated  for  the  first  twelve 
hours.  The  treatment  of  varicosities  in  connection  with  ulcers  of  the  leg  will  be 
given  in  another  chapter  (Ulcers). 

'  "New  York  Medical  Journal,"  July  27,  1907. 


CHAPTEE    VII 

AJ»T:UEISiI LIGATURE COilPEESSIOX AKTERIOKKHAPHT SPECIAL     A^'Et7BI.SlIS 


Ax  aneurism  is  a  sacculated  tumor,  the  cavity  of  whicli  communicates  with  an 
artery,  and  in  rare  instances  also  ■iri.th  a  rein. 

They  may  be  classified  as  spherical,  fusiform,  and  dissecting. 

A  spherical  aneurism  is  one  in  which  the  trmior  is  well  defined,  its  diameter 
being  larger  than  that  of  the  opening  of  communication  with  the  vessel.  It  may 
spring  from  any  portion  of  the  arterial  wall  (Fig.  145,  e)  or,  in  rare  instances, 
the  vessel  waUs  may  yield  in  all  directions  to  form  the  tumor  (Fig.  lib,  c). 

A  fusiform  aneurism  is  one  in  which  there  is  a  gradual  and  general  dilatation  of 
an  artery  in  its  entire  circumference  (Fig.  1-1-5.  a,  b).  A  spherical  aneurism  may 
occasionally  develop  from  the  wall  of  a  fusiform  dilatation. 

A  dissecting  aneiirism  is  one  in  which,  owing  to  pathological  changes  in  the 
intima,  the  blood  insinuates  itself  between  the  inner  coat  and  the  adventitia,  dis- 
sects the  intima  from  the  media  and  adventitia,  and  reenters  the  vessel  at  a 
distant  opening. 

Aneurisms  are  further  divided  into  the  true  and  false.  To  the  former  belong 
all  tumors  the  walls  of  which  are  composed  of  the  waUs  of  the  vessels  from  which 
thej"  spring;  to  the  latter  belong  those  tumors  the  walls  of  which  are  composed  of 
inflammatory  new-fonued  tissue. 

Cause. — A  true  aneurism  is  always  preceded  by  arteritis,  which  results  in  athe- 
romatous degeneration  of  the  normal  elements  which  compose  the  arterial  wall. 

The  pathology  of  arteritis  and  the  relation  of  this  condition  to  various  dys- 
crasiaj — as  s}"philis,  nephritis,  gout,  rheumatism,  etc. — have  been  given  in  a  pre- 
ceding chapter.  S^Tjliilis  improperly  treated  indiices  aneurism  in  a  large  proportion 
of  cases.  The  relation  of  violence  to  these  tumors  is  important.  Xo  matter  how 
severe  the  dyscrasia  and  the  general  condition  of  arteritis,  which  is  a  part  of  it,  it 
is  well  known  that  in  the  large  majorit}'  of  cases  aneurisms  develop  at  those  points 
in  the  arterial  system  wliicli  are  subjected  to  the  greatest  violence  from  heart  action, 
or  muscular  or  mechanical  pressure.  Thus  the  arch  of  the  aorta,  and  that  portion 
of  the  arch  in  the  direct  axis  of  the  left  ventricle,  is  very  prone  to  aneurism,  as  are 
the  great  vessels  near  their  origin  from  the  aortic  curve.  The  popliteal  arteries, 
subjected  as  they  are  to  violence  in  forced 
flexion  of  the  legs,  are  frequently  the  seat  of 
aneurismal  dilatations. 


Fig.  146. 
Varicose  aneurism. 


Fig.  147. 
Aneurismal  va: 


From  a  study  of  the  various  conditions  which  produce  aneurisms,  it  is  evident 
that  the  normal  wall  of  an  artery  cannot  form  the  sac  of  the  aneurism.     Some  of 

93 


94  ANEURISMS 

the  normal  anatomical  elements  may  be  25resent  in  the  sac,  but  the  integiity  of 
the  whole  is  impaired. 

An  aneurism  may  in  rare  instances  communicate  with  a  vein  {varicose  aneu- 
rism) (Fig.  146).  The  direct  communication  of  a  vein  and  artery  without  a  sac 
is  known  as  aiieurismal  varix  (Fig.  147). 

If  an  aneurismal  tumor  be  examined,  it  will  be  found  to  contain  coagulated 
blood  in  all  stages  of  fibrillation.  The  peripheral  portion  of  the  clot  is  composed 
of  irregular  laminte,  and,  if  examined  with  the  microscope,  the  laminated  appear- 
ance is  found  to  be  due  to  alternate  layers  of  white  corpuscles,  and  upon  these  a 
deposit  of  fibrin.  As  the  center  of  the  tumor  is  approached,  the  coagulation  is  evi- 
dently more  recent,  while  in  the  cavity  of  the  aneurism  a  soft  post-mortem  clot  is 
usually  found.    . 

Fusiform  aneurism  occurs  most  frequently  in  the  thoracic  aorta,  with  especial 
preference  for  the  arch.  It  may  affect  the  entire  aorta,  and  the  great  vessels  de- 
rived from  it.  Xot  only  is  the  diameter  of  the  arteries  increased,  but  the  hyper- 
trophy results  in  a  considerable  increase  in  their  length.  Not  infrequently  a  group 
of  fusiform  expansions  may  be  seen  with  strips  of  sound  and  non-dilated  artery 
intervening.  Calcareous  deposits  occur  in  patches,  and  seem  to  give  strength  to 
the  walls,  since  those  portions  give  way  more  readily  which  are  not  the  seat  of 
calcification. 

Coagulation  is  not  apt  to  occur,  as  in  sacculated  aneurisms;  in  fact,  it  is  a 
rare  condition.  Fusiform  aneurisms  develop  slowly,  and,  as  a  rule,  are  painful 
and  dangerous  only  when,  by  reason  of  their  large  growth,  they  exercise  undue 
pressure  upon  important  organs.  Thus,  in  dilatation  of  the  transverse  arch,  or  of 
the  right  subclavian,  spasm  of  the  glottis  occurs  from  irritation  of  the  recurrent 
laryngeal  nerves,  or  respiration  and  deglutition  may  be  seriously  embarrassed  by 
direct  comjiression  of  the  trachea  or  oesophagus.  Fusiform  dilatation  of  the  ab- 
dominal aorta  may  produce  serious  results  from  disturbance  of  the  vaso-motor 
system,  by  eomjDression  of  the  s}'mpathetic  ganglia  near  the  diajDhragm,  by  partial 
or  complete  occlusion  of  the  thoracic  duct,  etc. 

Dissecting  aneurisms  are  rare  as  compared  with  the  other  two  varieties.  The 
dissection  or  lifting  of  the  thin  lining  membrane  of  the  artery  from  the  media 
usually  occurs  in  the  long  axis  of  the  vessel.  If  the  middle  and  outer  coats  do  not 
become  involved  in  the  degeneration  wliich  has  affected  the  inner  coat,  this  form 
of  aneurism  may  continue  indefinitely,  without  leading  to  a  fatal  termination, 
although  the  danger  of  embolism  cannot  be  overlooked. 

If  the  other  layers  give  waj',  a  sacculated  aneurism  is  formed,  with  the  ad- 
ventitia  for  the  sac,  or  rupture  may  occur,  leading  to  fatal  extravasation. 

A  false,  or  so-called  "  diffuse  "  aneurism  results  from  the  solution  of  continuity 
in  all  the  coats  of  the  vessel  wall,  and  the  sudden  diffusion  of  blood  into  the  peri- 
arterial tissues.  The  extravasation  continues  until  the  resistance  of  the  surround- 
ing tissues  is  equal  to  the  pressure  of  the  column  of  blood  within  the  vessel.  As 
a  result  of  the  extravasation,  an  inflammatory  process,  of  variable  intensity  and 
usually  non-infective,  is  established,  wliich  results  in  the  formation  of  a  limiting 
membrane,  or  aneurismal  sac. 

The  prognosis  in  aneurism  varies  under  widely  differing  conditions.  In  gen- 
eral it  is  a  grave  affection,  the  gravity  depending,  in  a  great  degree,  upon  the 
location  and  character  of  the  tumor  and  the  physical  condition  of  the  individual 
affected.  An  aneurism  of  the  cranial  cavity  will  produce  rapidly  serious  effects 
by  compression  of  the  brain.  The  gravity  of  a  prognosis  diminishes  as  the  loca- 
tion of  the  tu.mor  is  removed  from  the  cavities.  Aneurism  (especially  the  saccu- 
lated variety)  of  the  aorta,  innominate,  subclavian,  or  iliac  arteries,  is  an  exceed- 
ingly dangerous  affection,  while  the  same  condition  in  the  distal  arteries  jdelds 
readily  and  safely  to  surgical  interference  in  the  great  majority  of  cases.  The 
prognosis  may  also,  in  part,  depend  upon  the  degree  of  discomfort  experienced 
by  the  patient,  from  the  effects  of  pressure  upon  contiguous  organs.  Neuralgia 
of  the  most  painful  and  obstinate  kind,  resulting  from  pressure  of  the  tumor  upon 
a  neighboring  nerve,  may  hasten  a  fatal  termination  by  loss  of  sleep  and  rest, 
and  the  general  impairment  of  nutrition.     Occlusion  of  the  accompanying  vein  may 


ANEURISMS  95 

occur,  producing  oedema  and  gangrene.  Again,  the  gravity  of  the  prognosis 
is  increased  when,  by  reason  of  its  location,  the  sac  of  an  aneurism  is  in  contact 
with  a  bony  surface,  since  rupture  is  not  infrequently  precipitated  by  attrition 
against  the  roughened  bone. 

The  -si/mptoms  of  aneurism  are,  in  gi-eat  part,  local.  They  refer  to  the  direct 
development  and  effect  of  the  tumor.  A  sense  of  unusual  throbbing,  pain  more  or 
less  severe,  and  swelling  in  the  line  of  an  artery  (when  the  aneurism  is  outside  of 
a  cavity)  which  pulsates  with  the  cardiac  systole,  which,  when  not  resting  upon 
a  hard  surface,  is  expansile  in  all  directions,  and  which  gives  to  the  sense  of  touch 
a  tremor  not  easily  described  but  readily  appreciated,  are  symptoms  which  poiat 
in  general  to  the  diagnosis  of  aneurism.  The  stetlioscope,  applied  to  the  tumor, 
conveys  to  the  ear  the  peculiar  sound  ("Iruit")  caused  by  the  passage  of  the 
blood  current  from  the  naiTow  vessel  into  the  expanded  anettrismal  sac  and  out 
again.  If  the  tumor  be  situated  upon  one  of  the  arteries  of  the  extremities,  com- 
pression upon  the  cardiac  side  will  cause  a  cessation  of  the  pulse  tremor  and  bruit, 
and  diminution  of  the  swelling,  while  pressure  upon  the  distal  side  will  tempo- 
rarily exaggerate  these  SATnptoms. 

'Wlien  an  aneurism  is  developed  as  a  result  of  a  wound  of  an  artery,  the  im- 
mediate s^Tnptoms  of  hcemorrhage  and  swelling,  with  the  pulsating  character  of 
the  tumor,  will  clearly  indicate  its  presence.  The  differentiation  is  chiefly  between 
solid  or  cystic  tumors,  wliich  develop  along  the  line  of  the  artery,  and  are  lifted 
by  the  arterial  pulsation.  Abscesses,  or  serous  cysts,  are  the  most  difficult  to 
lecognize.  In  the  formation  of  an  abscess  there  is  a  previous  history  of  inflam- 
mation. An  aneurismal  tumor  expands  equally  in  all  directions,  while  any  other 
tumor  travels  with  the  arterial  pulse  in  one  direction  only — that  of  least  resist- 
ance. In  cases  of  great  difficulty  of  diagnosis  it  will  be  justifiable  to  aspirate  the 
tmnor  with  the  finest  hypodermic  needle. 

Left  to  nature,  the  progress  of  an  aneurism  is,  with  rare  exceptions,  to  a  fatal 
termination.  The  deposit  of  fibrillated  fibrin  within,  and  the  inflammatory  new- 
formed  tissue  without,  may  retard,  but  rarely  arrests,  the  progress  of  the  disease. 
Added  to  the  danger  of  death  fi'om  rupture  of  the  sac,  or  compression  of  neigh- 
boring organs,  is  that  of  inflammation  and  sloughing  as  the  result  of  infection  or 
overtension  of  the  skin  as  the  tumor  approaches  the  surface.  The  hope  of  recovery 
is  in  the  gradual  deposition  of  fibrin  within  the  sac,  causing  its  ultimate  occlusion. 
or  that  of  the  vessel  or  vessels  immediately  connected  with  it.  The  danger  of 
gangrene  in  the  parts  beyond  the  tumor  is  lessened  with  the  gradual  establishment 
of  the  collateral  circulation,  while  the  sac  and  its  contents  are  less  apt  to  inflame 
than  when  the  occlusion  is  sudden  and  the  clot  recent. 

The  treatment  of  aneurism  is  constitutional  and  local.  The  constitutional 
treatment  is  directed  toward  the  judicious  support  of  the  physical  powers  of  the 
patient,  the  relief  from  pain,  and  the  production  of  a  condition  of  the  blood  favor- 
able to  a  deposit  of  fibriUated  fibrin  in  the  tumor. 

The  local  measures  are  directed  to  the  mechanical  control  and  arrest,  either 
gradual  or  immediate,  of  the  circulation  in  the  anetirism,  with  the  same  end  in 
view,  namely,  the  formation  of  fibrin  within  the  sac. 

Constitutional  measures  alone  offer  little  hope  of  a  cure,  and  are  applicable  only 
to  cases  where  the  dangers  of  operative  interference  are  sufficient  to  contra-indicate 
any  surgical  procedure.  In  this  plan  of  treatment  rest  in  bed  is  the  first  and 
essential  requirement.  In  conjunction  with  this  there  may  be  administered  cer- 
tain remedies  which  diminish  the  rapidity  of  the  circulation,  or  affect  the  blood 
vessels  or  blood  in  such  a  manner  that  the  gradual  deposit  of  fibrin  in  the  sac  is 
produced.  Valsalva's  method  of  rest  in  bed,  venesection,  and  gradual  starvation, 
in  order  to  slacken  the  blood  current  and  thus  cause  coagtdation  in  the  aneurism, 
is  now  almost  entirely  abandoned. 

Tufnell  modified  Valsalva's  method  by  omitting  bloodletting  and  substituting 
a  restricted  diet,  with  the  minimum  of  fluids.  Eest  in  the  recumbent  position 
must  be  rigidly  enforced.  Among  the  remedies  wliich  have  been  recommended  for 
internal  administration,  iodide  of  potassiimi  is  most  important.  It  is  especially  effi- 
cacious in  syphilitic  aneurism,  and  it  is  often  essential  to  combine  mercury  with  it. 


96 


ANEURISMS 


In  the  local  treatment  of  aneurism  the  most  approved  measures  are  compres- 
sion, the  ligature  with  or  without  excision,  and  arteriorrhaphy  (Matas). 

Compression  may  be  employed  on  the  cardiac  side  of  an  aneurism,  close  to 
the  tumor,  without  an  intervening  collateral  branch,  or  at  a  distance  from  the 
sac,  with  one  or  more  intervening  branches.  It  may  be  employed  on  the  distal 
side,  with  or  without  intervening  anastomosis,  or  directly  to  tlie  surface  and  back 
of  the  tumor,  or,  again,  on  both  peripheral  and  central  sides,  with  or  without 
direct  compression  of  the  aneurism. 

The  ligature  may  be  applied  on  the  cardiac  side  of  the  tumor,  there  being  one 
or  more  branches  given  off  between  the  ligature  and  the  sac  (Hunter's  method), 
or  without  an  intervening  branch  (Anel),  or  on  the  distal  side  without  (Brasdor), 
or  witli  an  intervening  branch  (Wardrop),  or  close  to  the  tumor  on  both  tlie  distal 
and  cardiac  side,  with  or  without  extirpation  of  the  tumor  (Antyllus)    (Fig.  148). 


Antyllus'  method. 


Brasdor's  method. 


When  interrupted  pressure  upon  the  main  trunk,  on  the  cardiac  side  of  an 
aneurism,  is  possible,  it  is  the  first  method  of  treatment  to  be  adopted.  It  can 
only  be  contra-indicated  when  the  tumor  is  so  near  to  the  great  cavities  from  which 
the  arteries  emerge  that  there  is  not  sufficient  room  for  its  accomplisliment,  or 
when,  on  account  of  the  anatomical  arrangement  of  contiguous  nerves  and  veins, 
compression  is  painful  or  inexpedient,  or  when,  as  will  occur  only  in  exceptional 
instances,  rupture  is  imminent;  then  the  ligature  is  demanded. 

It  is,  in  general,  advisable  to  apply  compression  on  the  cardiac  side  of,  and 
some  distance  from,  the  tumor,  where  the  vessel  wall  is  more  apt  to  be  normal. 
For  example:  In  a  popliteal  aneurism  the  patient  is  placed  in  the  position  of  least 
discomfort  to  himself  and  most  convenient  for  the  operator.  Should  the  pressure 
cause  pain,  cocaine  infiltration,  to  which  morphia  may  be  added,  will  usually 
suffice,  but  in  extreme  cases  a  general  ansesthetic  may  be  employed  for  an  hour  or 
two  if  necessary.  Compression  is  made  by  the  thumb  directly  over  the  femoral 
artery,  where  it  crosses  the  rim  of  the  pelvis,  and  it  should  be  firm  enough  to  very 
appreciably   diminish   the  pulsation   in  the   aneurism  and  to   entirely  arrest   the 


ANEURISMS  97 

current  for  a  minute  or  two  at  frequently  repeated  intervals.  Eelays  of  assist- 
ants are  required  with  tlie  digital  method,  which  should  be  continued  for  one 
or  two  or  three  hours,  and  repeated  daily,  or  oftener,  if  necessary  to  produce 
consolidation. 

The  elastic  bandage  skillfully  adjusted  will  enable  the  operator  to  dispense 
with  the  more  tiresome  digital  compression.  The  small  rubber  ball  or  compress 
resting  immediately  upon  the  artery  should  be  so  adjusted  that  the  circulation  in 
the  vein  is  not  interfered  with.  The  pressure  should  be  very  slight  at  first,  and 
gradually  increased  as  it  may  be  tolerated.  It  is  not  intended  to  be  sufficient  to 
entirely  occlude  the  artery.  Should  pain  be  felt  in  the  skin  or  in  the  anterior 
crural  nerve,  which  lies  just  to  the  outer  side,  it  may  be  relieved  by  careful 
cocaine  infiltration  repeated  every  half  hour  or  hour  without  removing  the  com- 
press ;  and  should  soreness  result,  the  point  of  pressure  may  be  changed  to  Scarpa's 
space  or  Hunter's  canal. 

This  metliod  may  be  used  continuously  or  interruptedly  until,  as  a  resiilt  of 
slowing  the  current,  the  deposit  of  fibrin  in  the  cavity  of  the  aneurismal  sac  has 
resulted  in  complete  solidification. 

Direct  pressure  upon  the  tumor  has  also  been  employed  with  success,  but  it  is 
not  so  safe  as  compression  on  the  proximal  or  distal  side. 

Should  pressure  fail  and  the  application  of  the  ligature  become  necessary,  the 
surgeon  may  choose  between  the  method  of  Hunter  and  Antyllus,  Wardrop,  Anel, 
or  Brasdor  (Fig.  148). 

A  commendable  feature  of  the  Hunter  method  is  that  the  ligature  is  applied 
at  some  distance  from  the  aneurism,  where  the  artery  is  more  apt  to  be  in  a  healthy 
condition;  but  for  this,  the  method  of  Anel  would  be  preferable,  since  the  danger 
of  gangrene  would  be  less. 

If,  on  account  of  pressure  upon  contiguous  organs,  excision  of  the  tumor  is 
demanded,  the  method  of  Antyllus  should  be  employed. 

Deligation  on  the  distal  side  of  an  aneurism  has  been  done  with  more  or  less 
success  in  aneurism  of  the  large  vessels  springing  directly  from  the  arch  of  the 
aorta,  and  is  justified  on  account  of  the  very  great  danger  when  a  ligature  is  applied 
between  the  tumor  and  the  heart. 

Wardrop's  method  is  the  reverse  of  Hunter's,  while  Brasdor's  is  the  reverse  of 
Anel's  (Fig.  148). 

Within  recent  years  Prof.  Rudolph  Matas  has  devised  the  operation  of  endo- 
aneurismorrhaphy. 

Under  favorable  conditions — i.  e.,  when  the  aneurism  is  sacciform  in  type,  and 
in  which  the  parent  trunk  retains  its  continuity  and  normal  outline,  the  aneurism 
being  simply  a  sac  grafted  on  the  vessel — the  operation  is  restorative.'^  The  blood 
supply  is  controlled  eitlier  by  digital  compression  or  the  sterile  tape  passed  around 
the  vessel  and  twisted  just  enough  to  arrest  the  current,  but  not  to  injure  the 
intima  and  media.  The  sac  is  incised  in  its  longest  axis  and  the  clot  washed  out. 
The  opening  leading  from  the  sac  into  the  artery  is  then  exposed  inside  the  aneu- 
rism, and  is  readily  closed  by  a  continuoris  suture  of  fine  chromicized  catgut,  which 
penetrates  through  all  the  coats  of  the  sac  at  the  margin  of  the  orifice  of  com- 
munication. The  sac  is  then  obliterated  by  bringing  its  endothelial  surfaces  to- 
gether with  buried  sutures  of  the  same  material.  The  constriction  is  now  removed 
and  the  wound  dressed  in  the  usual  manner. 

Reconstructive  arterioplasty  is  applicable  in  a  fusiform  aneurism  in  which  the 
coats  of  the  sac  are  firm,  elastic,  and  resistant,  the  two  openings  leading  to  the 
main  artery  being  on  the  same  level,  in  close  proximity,  and  situated  at  the  bottom 
of  a  superficial  or  readily  accessible  sac.  The  continuity  of  the  parent  artery  may 
be  restored  by  making  a  new  channel  out  of  the  sac  walls,  which  can  be  brought 
together  by  suture  over  a  guide  of  suitable  size  (velvet  catheter  or  drainage  tube) 
inserted  into  the  proximal  and  distal  openings  of  the  aneurism.  Before  tying  the 
last  sutures,  the  guide  is  removed,  leaving  behind  a  channel  corresponding  to 
the  outline  of  the  original  artery    (Fig.    149).     The  sac  is  then  obliterated  by 

•  Matas  reports  seven  operations  of  this  character  by  American  surgeons,  all  successful,  and 
two  from  foreign  sources. 


98  ANEURISMS 

approximating  its  surfaces  with  buried  catgut  sutures,  as  in  the  preceding  oper- 
ation.^ 

Obliterative  arteriorrliapluj  is  especially  applicable  to  aneurisms  situated  so  near 
the  aorta  that  the  danger  from  the  ligature  in  continuity  is  very  great,  or  elsewhere, 
in  the  course  of  an  artery,  the  walls  of  which  have  undergone  atheromatous  or  cal- 
careous degeneration.  It  consists  in  opening  the  sac  freely  without  in  any  way 
disturbing  its  surroundings,  and  in  closing  all  arterial  orifices  by  suture.     The  sac 


Fig.  149. — Matas'  operation  of  reconstructive  arterioplasty.  A,  Showing  the  method  of  closing  the 
orifices  and  constructing  a  new  arterial  channel  in  a  fusiform  aneurism  ;  B,  removal  of  the  guide. 
(Fowler^s  Surgery.) 

is  then  obliterated  by  approximating  its  walls  by  buried  sutures  as  before,  and 
closing  the  wound  with  or  without  drainage.  According  to  Matas,  this  procedure 
is  indicated,  in  aneurisms  in  which  the  sac  is  of  fusiform  type,  with  two  or  more 
orifices  of  supply,  and  in  which  the  parent  artery  is  entirely  lost  at  the  seat  of  the 
aneurism  by  blending  with  the  aneurismal  sac. 

This  procedure  should  largely  reduce  the  mortality  which  has  heretofore  resulted 
in  deligation  of  the  innominate,  the  first,  second,  and  third  portions  of  the  sub- 
clavian arteries,  and  the  common  iliacs,  for  the  cure  of  aneurisms  distal  to  the 
ligature.  It  has  already  been  successfully  performed  in  a  case  of  subclavio-axillary 
aneurism. 

Teasing  the  Sac. — Macewen  successfully  practiced  this  method,  which  consists 
of  the  introduction  of  a  long,  delicate  sterile  needle  into  the  cavity  of  the  sac, 
bringing  the  point  of  the  needle  along  the  wall  in  various  directions,  by  this  means 
exciting  more  rapid  formation  of  coagulum  in  the  roughened  wall.  In  aneurisms 
at  the  root  of  the  neck,  as  of  the  ascending  or  transverse  aorta,  of  the  innominate 
or  carotid  arteries,  or  of  the  subclavians  close  to  the  carotid,  the  danger  of  clot 
being  washed  into  the  vessels  leading  to  the  brain  should  not  be  overlooked. 

Acupuncture  consists  in  the  introduction  of  needles  or,  preferably,  silver  pins. 
In  one  case  of  large  thoracic  aneurism  of  the  ascending  aorta,  in  which  I  was 
afraid  to  employ  Macewen's  method  for  fear  of  clot  being  carried  to  the  brain, 
under  careful  aseptic  precautions,  I  introduced  about  two  dozen  silver  pins,  two 
inches  long,  to  their  full  depth  into  the  aneurismal  sac,  the  pins  being  about  one 
fourth  of  an  inch  apart.  They  were  left  in  from  twelve  to  twenty-four  hours,  and 
produced  well-marked  coagidation.  The  operation  was  repeated  twice  in  this  case;' 
the  aneurism  diminished  rapidly  in  size,  and  the  patient  was  discharged  much 
improved.  He  returned  to  his  work,  and  a  year  later  died  from  dislodgment  of 
a  clot  which  was  swept  into  the  carotid  artery,  causing  fatal  cerebral  anaemia. 

'  Five  cases  of  this  procedure  are  reported  by  American  surgeons,  in  two  of  which  relapses 
have  occurred. 


ANEURISMS  99 

Massage  or  hneading  has  been  successful^  performed  in  a  few  instances.  The 
aneurism  is  manipulated  with  the  intention  of  detaching  from  the  sac  enough  of 
the  fibrillated  clot  to  plug  up  the  efferent  vessel  and  thereby  practically  tie  the 
artery  on  the  distal  side  (Brasdor).  It  is  of  doubtful  propriety  except  in  small 
aneurisms  situated  in  the  arms  or  legs.  The  danger  of  embolism  in  the  cerebral 
circulation  is  too  great  to  justify  this  or  any  similar  procedure  upon  an  aneurism 
connected  with  a  vessel  leading  toward  the  brain. 

Flexion  or  posture  is  practically  a  method  of  direct  compression,  using  the 
normal  tissues  for  a  pad.  It  is  employed  in  popliteal  aneurism,  where  the  knee  is 
flexed  and  fastened  so  as  to  compress  and  partially  occlude  the  tumor  between  the 
tibia  and  fibula,  and  the  femur.  It  is  a  justifiable  method  in  rare  instances.  The 
same  practice  may  be  instituted  at  the  elbow,  but  is  impracticable  at  the  axilla  on 
account  of  the  arrangement  of  the  nerves. 

The  introduction  of  watch-spring,  silver-wire,  liorseliair,  catgut  coil,  or  any 
other  foreign  solid  substance  into  the  cavity  of  an  aneurism  will  rarely  be  justi- 
fiable except  as  a  last  resort  in  cases  where  the  ligature  or  compression  is  impos- 
sible. For  its  execution  a  pointed  canula  is  usually  employed,  which,  having  been 
introduced  into  the  sac,  the  wire  or  gut  is  pushed  through.  The  quantity  used 
varies  from  two  or  three  feet  up  to  several  yards.  More  of  the  catgut  may  be 
introduced  than  of  the  metal,  and  the  animal  ligature  should  always  be  preferred 
if  this  procedure  is  adopted. 

Special  Aneukisms 

Aneurism  of  the  Thoracic  Aorta. — The  ascending  and  transverse  portions  of 
the  arch  are  most  frequently  affected.  If  the  dilatation  is  fusiform,  both  of  these 
segments  are  apt  to  be  involved ;  if  it  is  a  sacculated  aneurism,  it  is  usually  con- 
fined to  one  or  the  other  segment.  Sacculated  aneurism  of  the  ascending  arch 
high  up,  or  of  the  transverse  arch,  usually  involves  the  orifice  of  one  or  more  of 
the  great  vessels  which  originate  here,  although,  as  in  the  specimen  figured  below 
(see  Fig.  151),  not  infrequently  the  mouth  of  the  sac  opens  close  to  these  vessels, 
but  does  not  involve  them. 

The  diagnosis  of  aneurism  of  the  arch  is  generally  obscure  until  the  dilatation 
has  advanced  to  such  an  extent  that  pressure  symptoms  are  evident.  Pain  of  vary- 
ing intensity  may  be  present  in  the  earlier  stages  of  development  of  both  fusiform 
and  sacculated  aneurism.  A  symptom  of  great  diagnostic  value  is  disturbance  of 
the  larjmgeal  muscles,  due  to  pressure  upon  the  recurrent  laryngeal  nerve  of  the 
left  side.  This  occurs  in  dilatation  of  the  transverse  or  descending  segment  of 
tlie  arch.  The  aneurismal  bruit  may  be  recognized  as  soon  as  the  sacculation  is 
well  advanced.  Interference  with  respiration,  or  degliTtition,  or  the  return  circu- 
lation in  the  veins,  is  among  other  and  important  pressure  symptoms. 

The  appearance  of  a  tumor  with  an  expansile  pulsation  synchronous  with  the 
cardiac  systole,  in  the  upper  thoracic  region,  determines  the  diagnosis  of  aneurism. 
The  differentiation  of  dilatation  of  the  arch,  from  a  similar  condition  of  the  in- 
nominate, left  carotid,  or  left  subclavian  in  the  thorax,  is  difficult,  and  at  times 
impossible.  A  number  of  errors  in  diagnosis  by  competent  and  honest  observers  are 
on  record. 

The  following  points  will  aid  in  arriving  at  a  diagnosis :  The  tumor  in  aneurism 
of  the  ascending  arch  is  usually  first  appreciated  to  the  right  of  the  sternum,  be- 
tween the  clavicle  and  the  third  rib.  The  pressure  symptoms  do  not  affect  the  voice 
until  the  tumor  is  recognizable  in  the  right  side  of  the  root  of  the  neck,  where  it 
involves  the  right  recurrent  laryngeal  nerve.  Eespiration  may  be  interfered  with, 
or  cough  produced  hj  compression  of  the  right  bronchus.  This  condition  will  be 
recognized  by  the  hissing  rales  distributed  over  the  area  of  the  right  lung.  Aneu- 
rism of  the  transverse  arch  is  usually  first  recognized  to  the  left  of  the  sternum 
on  about  the  same  plane  as  for  the  ascending  segment.  Laryngoscopical  examina- 
tion will  demonstrate  that  whatever  of  muscular  paresis  exists  is  confined  to  the 
left  vocal  bands.  If  the  tumor  rises  into  the  neck,  its  appearance  will  have  been 
preceded  by  pressure  symptoms  of  longer  duration  and  greater  severity  than  in 
either  innominate,  carotid,  or  subclavian  aneurism. 


100 


ANEURISMS 


Innominate  aneurism  iisuall}^  appears  at  the  upper  margin  of  the  sternum  in 
the  space  between  the  two  tendons  of  origin  of  the  right  sterno-mastoid  muscle, 
or  in  the  interclavicular  notch.  The  disturbance  of  the  circulation  through  this 
vessel  so  affected  may  be  recognized  by  the  difference  in  the  force  and  character 
of  the  pulse  wave  in  the  radial  arteries  of  the  two  arms.  In  aortic  aneurism,  when 
the  innominate  is  not  comjiressed  by  the  tumor,  the  pulse  wave  will  be  the  same 
in  both  arms.  It  must,  however,  be  borne  in  mind  that  in  sacculated  aneurisms, 
springing,  as  they  not  infrequently  do,  from  the  arch  in  immediate  proximity  to 
the  orifice  of  the  innominate,  and  rising  to  the  root  of  the  neck,  in  front  of  or 
behind  this  artery,  a  positive  diagnosis  is  scarcely  possible.  The  pressure  on  the 
innominate  may  retard  or  weaken  the  right  radial  pulse,  when  this  vessel  is  not 
involved,  while  the  aneurismal  bruit  is  present  in  the  exact  location  of  this  vessel. 

Aneurism  of  the  left  carotid  artery  will  first  appear  at  the  left  sterno-elavicular 
articulation  in  the  line  of  this  vessel.  The  murmur  will  be  transmitted  toward  the 
distribution  of  this  vessel,  and  will  not  be  heard  in  its  fellow  opposite. 


Fig.  150.— The  author's 


•■  of  aneurism  of  the  ascending  aorta. 


When  the  left  subclavian  is  involved,  the  swelling  will  usually  appear  to  the  left 
of  the  sterno-mastoid  muscle,  and  the  pulse  in  the  left  radial  will  differ  from  that 
of  the  right.  When  the  descending  aorta  is  the  seat  of  aneurism,  the  diagnosis  is 
still  more  obscure.  The  peeiiliar  murmur  is  most  easilv  recognized  by  placing 
the  stethoscope  to  the  left  of  the  vertebral  column  in  "the  interscapular  space. 


ANEURISMS 


101 


The  chief  pressure  s3iaptoms  are  those  which  affect  deglutition  and  lift  the  heart 
forward. 

The  clinical  history  of  aneurism  of  the  thoracic  aorta  usually  ends  in  the  death 
of  the  individual.  In  addition  to  the  sj-mptoms  given  in  the  method  of  diagnosis, 
the  gradual  expansion  of  the  timior  leads  to  more  painful  and  graver  conditions. 
Anxiety,  loss  of  sleep,  pain,  and  cough  usually  prostrate  the  patient;  erosions  of 


Fig.  151 . — Section  through  the  long  diameter  of  the  tumor. 

the  ribs,  sternum,  clavicles,  and  vertebra3  occur,  and  sloughing,  septic  aljsorption, 
or  htemorrhage  may  produce  a  fatal  termination. 

The  medical  treatment  is  rest  in  bed, "and  the  safe  and  judicious  combination 
of  Valsalva's  and  Tufnell's  methods  as  given.  The  surgical  treatment  is  of  the 
most  heroic  order,  and  should  not  be  instituted  until  a  reasonable  trial  of  the  other 
methods  has  proved  them  as  inefScient,  as  death  is  inevitable.  This  treatment  is 
the  deligation  of  one  or  more  of  the  great  vessels  -which  are  derived  directly  or 
indirectly  from  the  arch — i.e.,  the  distal  operation. 

That  this  operation  is  Justifiable,  under  certain  conditions,  has  been  demon- 
strated. Among  a  number  of  cases  in  the  statistics  of  this  procedure,  the  following 
are  from  personal  exjDerience : 

On  the  21st  of  September,  1880,  I  tied  the  right  carotid  and  subclavian  arteries 
simultaneously  for  the  relief  of  an  aneurism  of  the  ascending  portion  of  the  aorta.^ 

•  For  a  full  report  of  this,  and  all  the  other  cases  up  to  that  date,  see  paper  by  the  author  in 
"American  Journal  of  the  Medical  Sciences,"  January,  1881. 


102  ANEURISMS 

The  history  of  the  aneurism  dated  bacli  sixteen  months.  Having  developed  rapidly, 
it  projected  througli  the  right  second  intercostal  space,  causing  such  pain  that  the 
operation  was  undertaken.  This  was  the  second  operation  which  had  knowingly 
been  undertaken  for  the  relief  of  aneurism  of  the  ascending  aorta.  Despite  the 
prostrated  condition  of  the  patient,  she  recovered,  the  tumor  diminished  perceptibly 
in  size,  became  more  solid,  and  her  general  condition  was  much  improved.  One 
month  after  the  operation  she  was  discharged  from  the  hospital,  and  traveled  to  a 
neighboring  State,  where  she  died,  one  year  later,  from  acute  diarrhoaa.  I  secured 
an  autopsy,  which  revealed  an  aneurism  (Figs.  150,  151)  as  large  as  an  orange 
springing  from  the  ascending  aorta,  at  its  junction  with  the  transverse  segment. 
The  orifice  of  the  tumor  was  an  oval,  about  half  an  inch  by  one  inch  in  extent. 
The  tumor  was  solidified  with  permanent  clot  on  its  lateral  and  posterior  aspects. 
On  the  upper  anterior  surface,  which  had  worn  away  the  sternum  and  second  rib, 
the  sac  was  thin,  with  a  recent  clot  which  filled  a  cavity  not  quite  an  inch  in  diam- 
eter. The  tumor  was  practically  solidified,  and  had  this  patient  not  returned  to  her 
dissipated  jjractices  (alcoholism),  I  do  not  doubt  that  her  recovery  would  have  been 
complete. 

Aneurism  of  the  thoracic  aorta  beyond  the  transverse  segment  is  not  amenable 
to  surgical  treatment. 

Aneurism  of  the  Innominate  Artery. — The  symptoms  of  this  formidable  lesion 
have  been  given  on  a  preceding  page.  It  is  frequently  complicated  with  aneurismal 
dilatation  of  the  aorta,  or  of  the  two  vessels  into  which  it  usually  bifurcates.  It 
will  be  interesting  to  study  the  results  of  operative  procedures  under  the  following 
subdivisions : 

1.  Innominate  Aneurism.  2.  Aortic  Innominate  Aneurism. — For  innominate 
aneurism,  (a)  the  double  simultaneous  distal  ligature  (carotid  and  third  division 
of  the  subclavian);  {'b)  the  double  non-simultaneous  distal  operation;  (c)  distal 
deligation  of  the  carotid  artery  alone;  {d)  distal  deligation  of  the  subclavian 
artery  alone. 

For  the  relief  of  innominate  aneurism,  simultaneous  deligation  of  the  right 
common  carotid  and  the  right  subclavian  artery  in  its  third  division  has  been  done 
twelve  times.  Eecovery  with  a  cure  more  or  less  complete  took  place  in  five  cases, 
while  death  occurred  in  seven.  It  is  probable  that  if  in  some  of  these  fatal  cases 
the  operation  had  been  performed  earlier,  the  ratio  of  mortality  would  have  been 
lower. 

In  one  instance  the  subclavian  artery  was  tied  a  year  before  the  right  carotid, 
resulting  in  a  cure,  the  patient  dying  from  phthisis  three  years  after  the  last 
operation.  In  a  second  case  the  carotid  was  tied,  with  temporary  improvement. 
Two  years  later  the  subclavian  was  ligated;  the  aneurismal  bruit  disappeared, 
resulting  in  the  consolidation  of  the  tum_or,  as  proven  by  an  autopsy  four  months 
later,  the  patient  dying  from  pleuritis  caused  by  a  fall  while  intoxicated.  In  a 
third  ease  the  interval  was  two  months  and  nine  days.  Immediate  and  temporary 
relief  followed  each  procedure.  The  sac  ruptured  on  the  forty-fourth  day  after 
the  last  operation.  In  a  fourth  ease  the  patient  was  not  benefited  by  tying  the 
carotid.  Three  months  later  the  subclavian  was  tied,  followed  by  death  from 
rupture  of  the  sac  on  the  twenty-first  day. 

In  fourteen  cases  the  distal  ligature  was  applied  to  the  right  carotid  for  the 
relief  of  innominate  aneurism.  In  only  one  instance  was  a  cure  effected,  and  in 
this  only  after  suppuration  occurred  in  the  sac.  Of  the  fourteen  cases,  eight 
ended  fatally. 

In  three  instances  the  subclavian  artery  in  the  third  division  has  alone  been 
tied  for  innominate  aneurism.  Each  case  recovered  with  marked  improvement, 
and  in  each  there  was  more  or  less  complete  solidification  of  the  tumor. 

With  any  of  these  operative  measures,  the  postural,  dietetic,  and  medicinal  treat- 
ment should  be  combined ;  in  fact,  this,  the  Tufnell  method,  enforced  with  extreme 
rigor  is  entitled  to  a  fair  trial  for  a  considerable  period  before  operation  is  done. 

Aneurism  of  the  Common  Carotid  Artery. — Aneurism  of  the  carotid  may  occur 
in  any  part  of  the  course  of  this  vessel,  being  in  rare  instances  intrathoracic  (when 
the  left  trunk  is  involved). 


ANEURISMS  103 

The  diagnosis  of  aneurism  of  the  left  carotid,  low  down,  depends  upon  the 
presence  of  the  aneurismal  bruit  over  the  tumor,  this  murmur  being  carried  along 
the  artery.  Pressure  symptoms  are  referable  to  the  pneumogastric  or  recurrent 
laryngeal,  or  to  distention  of  the  left  internal  jugular,  and  in  rare  instances  the 
left  subclavian  vein.  The  presence  of  the  swelling  is  usually  first  recognized  in 
the  space  between  the  two  tendons  of  origin  of  the  left  sterno-mastoid  muscle. 

Aneurism  of  the  vertebral  artery,  in  its  lower  portion,  may  be  differentiated 
from  that  of  the  carotid  by  compression  of  this  latter  vessel  high  up.  If  the  thumb 
be  placed  over  the  carotid,  at  its  bifurcation,  and  pressed  firmly  and  directly  back- 
ward against  the  vertebral  column,  such  compression  will  not  affect  the  circulation 
in  the  sac  of  a  vertebral  aneurism,  while  if  involving  the  carotid  it  would  be  visibly 
affected.  Then,  again,  vertebral  aneurism  is,  in  nearly  every  instance,  of  traumatic 
origin,  while  aneurism  of  the  carotid  is  almost  always  idiopathic. 

In  the  differential  diagnosis  of  these  two  lesions  higher  in  the  neck,  the  same 
method  is  applicable.  It  should  not  be  forgotten  that  careless  manipulation  of  a 
carotid  aneurism  may  detach  a  clot.  If  the  tumor  involve  the  carotid  or  its 
branches,  compression  of  the  primitive  trunk,  low  dowoi,  will  arrest  the  pulsation 
in  the  sac.  This  is  best  accomplished  by  relaxing  the  sterno-mastoid  muscle  of 
that  side,  and  grasping  the  vessel  between  the  thumb  and  finger  carried  behind  the 
muscle.  On  account  of  the  deep  seat  of  the  vertebral  artery  its  compression  by 
this  manoeuvre  is  impossible.  This  last  vessel  may  be  compressed  by  placing  the 
thumb  one  inch  directly  below  the  transverse  process  of  the  sixth  cervical  vertebra, 
and  pressing  backward.  Above  this  point  it  is  impossible,  since  the  vessel  runs  into 
the  vertebral  foramina?. 

The  ligature  between  the  aneurism  and  the  heart  is  the  safest  method  of  dealing 
with  an  aneurism  of  the  common  carotid  artery.  Direct  or  indirect  compression  is 
not  only  difficult,  but  dangerous,  since  cerebral  embolism  may  occur  from  the 
separation  of  a  fragment  of  clot. 

When  the  ligature  cannot  be  applied  on  the  cardiac  side,  distal  deligation  should 
be  done. 

Aneurism  of  the  external  carotid  artery  should  be  treated  by  the  ligature  on 
the  side  nearest  the  heart;  when  the  walls  of  the  common  trunk  and  the  beginning 
of  the  external  branch  are  normal,  the  ligature  may  even  be  safely  applied  directly 
in  tlie  crotch  of  bifurcation.  The  author  has  performed  this  operation  three  times, 
without  accident.  Should  this,  however,  be  impracticable,  the  common  and  internal 
carotid  should  be  tied  simultaneously.  The  external  carotid  artery  may  be  tied 
at  any  point  in  its  course,  regardless  of  the  origin  of  its  branches.^ 

Aneurism  of  the  internal  carotid,  in  the  neck,  should  be  treated  by  the  deligation 
of  this  vessel,  between  the  sac  and  the  common  trunk.  Should  this  be  not  feasible, 
the  common  and  external  carotid  should  be  tied,  together  ivith  all  branches  of  the 
external,  on  the  cardiac  side  of  the  ligature.  I  performed  this  operation  in  one 
instance,  resulting  in  the  rapid  and  permanent  cure  of  a  large  extra-cranial  aneu- 

'The  author  demonstrated  the  practicability  of  tying  the  external  carotid  artery  and  the 
surgical  necessity  for  this  operation  for  the  relief  of  all  lesions  in  the  distribution  of  the  external 
carotid,  rather  than  ligation  of  the  common  trunk,  which  up  to  that  time  was  almost  universally 
practiced. 

When  his  essays  on  the  arteries  were  published  (in  1878),  the  external  carotid  artery  to  that 
period  had  been  tied  in  only  91  instances,  with  a  death-rate  of  4J  per  cent.  There  was  not  a 
text-book  in  any  language  that  did  not,  at  that  time,  advise  the  ligature  of  the  common  trunk, 
rather  than  the  external  carotid,  for  a  lesion  within  the  distribution  of  the  latter  vessel. 

As  an  indication  of  the  influence  which  these  essays  had  in  determining  the  future  of  operations 
upon  this  vessel,  the  following  is  quoted  from  the  Third  American  Edition  of  "A  Manual  for  the 
Practice  of  Surgery,"  by  Thomas  Bryant,  F.R.C.S..  1881: 

"In  this  connection  the  views  of  Dr.  John  A.  Wyeth,  of  New  York,  deserve  great  attention, 
for,  in  his  prize  essays,  presented  to  the  American  Medical  Association  in  1878,  he  has  investigated 
the  subject  of  ligation  of  the  primitive  carotid  artery  and  its  branches  with  such  painstaking 
accuracy  that  his  paper  will  deservedly  become  classical.  He  has  collected  and  analyzed  789 
cases  of  ligation  of  the  common  carotid  artery,  91  instances  of  ligation  of  the  external,  and  18  of 
ligation  of  the  internal  carotid.  In  addition,  he  has  given  accurate  measurements  of  the  arteries 
in  121  subjects,  showing  the  range  of  variation  and  the  position  of  branches.  His  inferences  from 
this  astonishing  amount  of  research  are  at  variance  in  some  respects  with  the  surgical  teaching 
and  practice  of  the  day;  but  it  would  seem  that  the  profession  must  be  in  the  wrong,  rather  than 
he  who  has  considered  the  subject  in  such  a  thorough  and  scientific  manner." 


104  ANEURISMS 

rism  of  the  internal  carotid.  The  common  trunk  was  first  tied,  then  the  superior 
thyroid,  and  external  carotid,  just  above  its  origin. 

Aneurism  of  the  internal  carotid  may  occur  in  the  cavernous  or  cerebral  por- 
tions of  this  vessel.  In  the  petrous  canal  dilatation  is  practically  impossible.  Not 
infrequently  an  arterio-cavernous  aneurism  occurs  from  the  giving  way  of  the 
septum  between  these  two  vessels.  The  cause  may  be  traumatic,  as  in  fracture  at 
the  base  of  the  skull,  or  the  communication  may  be  established  without  appreciable 
cause. 

The  symptoms  of  aneurismal  dilatation  here  are  of  two  kinds:  those  referable 
to  pressure  iipon  the  brain  and  nerves,  and  those  due  to  interference  with  the 
return  venous  current  through  the  ophthalmic  vein.  If  the  arterio-venous  com- 
munication has  occurred,  exophthalmus  is  marked,  and  the  eyeball  is  projected  for- 
Avard  with  each  arterial  pulse.  Einging  in  the  ears,  dizziness,  with  varying  loss  of 
function  due  to  pressure,  are  other  symptoms. 

The  opldhalmic  artery  may  be  the  seat  of  aneurism  within  the  cranial  cavity 
or  in  the  orbit.  True  sacculated  intra-orbital  aneurism  of  this  artery  is  extremely 
rare,^  although  pulsating  tumors  (arterio-venous  aneurisms,  angeiomata,  cirsoid 
arterial  tumors,  etc.)  are  not  infrequent  in  this  locality.  The  chief  point  in  the 
diagnosis,  and  the  one  which  has  an  important  bearing  in  treatment,  is  compression 
of  the  carotid.  If  pulsation  ceases,  and  the  other  symptoms  disappear,  the  indica- 
tion is  clear  that  the  ligature  should  be  applied  to  this  vessel.  The  common  trunk 
should  be  tied,  in  order  to  cut  off  the  free  communication  between  the  branches 
of  the  external  carotid  and  the  ophthalmic  in  the  orbit.  In  my  Essays  are  given 
fifty-two  instances  in  which  this  operation  was  done  for  pulsating  non-malignant 
tumors  of  the  orbit,  with  a  death-rate  of  11.5  per  cent.''  About  seventy-five  per  cent 
of  recoveries  after  this  operation  result  in  cures.  In  severe  cases  extirpation  may  be 
necessitated. 

Aneurism  of  any  branch  or  branches  of  the  external  carotid  should  be  treated 
by  the  ligature  of  the  branch  involved,  or  the  external  trunk. 

Aneurism  of  the  Subclavian  Arteries. — The  subclavian  arteries  may  be  affected 
in  any  portion  of  their  extent,  although,  on  account  of  the  pressure  exercised  by 
the  two  scaleni  muscles,  this  division  is  less  frequently  involved.  The  seat  of 
this  disease  is  by  preference  in  the  third  portion,  the  first  division  being  next  in 
order.  Exposure  to  violence  or  muscular  effort  has  much  to  do  with  the  develop- 
ment of  subclavian  aneurism,  since  males  are  more  frequently  affected.  The  tu- 
mor is  found  on  the  right  side  in  the  majority  of  cases. 

The  first  portion  of  the  right  subclavian  is  also  frequently  involved  in  the 
progress  of  an  innominate  aneurism.  Upon. the  left  side  aneurism  of  the  thoracic 
portion  of  this  vessel  is  rare. 

Subclavian  aneurism  is  first  recognized  as  a  pulsating  tumor  behind  the  clavicle, 
and  to  the  outer  side,  or  behind  the  sterno-mastoid  muscle.  It  may  be  mistaken 
for  a  glandular  or  other  tvimor.  The  symptoms  which  have  been  detailed  will 
serve  as  a  guide  for  differentiation.  Difficulty  may  arise,  even  after  the  aneurismal 
character  of  the  swelling  has  been  recognized,  in  determining  from  what  vessel 
the  tumor  springs.  As  has  been  said,  the  progress  of  aortic  aneurism  gives  rise  to 
pulsation  and  pressure  symj)toms,  located  in  the  thorax  for  a  considerable  period 
prior  to  the  appearance  of  the  tumor  at  the  root  of  the  neck.  In  fact,  aneurism 
of  the  aorta,  in  many  instances,  produces  death  before  it  attains  such  magnitude. 
On  the  i-ight  side,  tins  knowledge  will  aid  materially  in  recognizing  the  seat  of 
the  lesion,  and,  fortunately,  aneurism  of  the  arch  and  subclavian  occurs  most 
often  on  this  side  of  the  body.  The  differentiation  of  aneurism  of  the  thoracic 
portion  of  the  left  artery,  from  the  same  lesion  of  the  arch,  near  the  origin  of 
the  subclavian,  is  more  difficult.  When  the  tumor  involves  the  subclavian  its 
appearance  in  the  neck  is  more  rapid  than  in  aortic  aneurism,  while  interference 
with  the  return  circulation  in  the  arm,  which  may  appear  early  in  the  history 

1  Prof.  Sattler's  classical  paijer  in  Graefe  and  Saemisch's  "  Handbuch  der  gesammter  Augen- 
heilkunde,"  Leipsic,  1880. 

2 "  Prize  Essays  of  the  American  Medical  Association,  1878,"  William  Wood  &  Co.,  New 
York. 


ANEURISMS  105 

of  subclavian  aneurism,  is  rare  when  the  aorta  is  the  seat  of  this  lesion.  Again, 
in  aneurism  of  the  second  or  third  portion  of  the  arch,  which  does  not  involve 
the  subclavian,  the  pulse  wave  in  the  left  radial  will  be  of  equal  force  and  syn- 
chronous with  that  of  the  right  side. 

In  the  treatment  of  subclavian  aneurism'^  the  methods  may  be  divided  into  the 
surgical,  the  postural,  medical,  and  dietetic,  and  the  palliative  or  expectant.  The 
emjjloj-ment  of  any  of  these  means  will,  again,  be  in  great  part  determined  by  the 
portion  of  the  artery  involved.  The  surgical  treatment  comprises  the  ligature 
or  compression  on  the  cardiac  or  distal  side;  or  pressure  applied  directly  to  the 
sac,  and  massage. 

Deligation  of  the  arferia  innominata  for  the  relief  of  subclavian  aneurism  pre- 
sents an  array  of  disasters  which  makes  it  imperative  in  the  surgeon  to  exhaust 
all  less  radical  measures  before  attempting  it.  It  lias,  however,  been  done  suc- 
cessfully, and  conditions  may  arise  which  will  justify  the  procedure.  When  it  is 
performed,  I  would  advise  a  removal  of  the  sternal  end  of  the  clavicle,  in  order 
to  expose  not  only  the  innominate  close  to  the  bifurcation,  but  also  the  branches 
which  arise  from  its  first  and  second  surgical  divisions  of  the  subclavian,  which, 
with  the  common  carotid,  should  also  be  tied  at  the  same  operation. 

I  would  also  advise  the  emplojTiient  of  a  broad  ligature,  which  would  be  less  liable 
to  cause  the  artery  to  cut  through  from  the  impact  of  the  current  coming  with 
such  force  at  this  point  directly  from  the  left  ventricle.  A  ligature  made  of  several 
strands  of  catgut,  ranged  side  by  side,  would  suffice,  or,  preferably,  a  portion  of 
the  sciatic  nerve  of  the  calf  treated  aseptically.  I  have  used  this  soft,  yet  strong, 
ligature  in  a  number  of  instances  with  complete  satisfaction;  not,  however,  in 
tying  so  large  a  vessel  as  the  innominate.  I  would  not  hesitate  to  employ  it  in 
this  dangerous  operation,  using  catgut  for  the  carotid  and  the  smaller  branches. 
If  all  the  branches  of  the  subclavian  were  tied,  and  this  vessel  ligated  in  its  tliird 
surgical  division  and  the  carotid  tied,  coagulation  would  of  necessity  take  place  in 
the  innominata. 

Ligature  of  the  subclavian  artery  in  its  first  or  second  surgical  divisions  has 
also  proved  disastrous  in  a  very  large  proportion  of  cases  in  which  it  has  been 
performed.  Under  aseptic  conditions  it  will  be  justified  in  extreme  cases,  the 
branches  given  ofE  from  the  first  and  second  divisions  being  tied  at  the  same  time. 
Before  resorting  to  any  such  procedures,  however,  the  danger  of  gangrene  to  the 
upper  extremity  should  be  seriously  considered. 

It  is  safe  to  conclude,  from  a  careful  study  of  the  results  in  the  treatment  of 
subclavian  aneurism,  that  the  ligature  on  the  proximal  side — that  is,  to  the  innomi- 
nate, carotid,  and  first  or  second  portions  of  the  subclavian  artery — should  not 
be  attempted  until  the  most  persistent  and  careful  application  of  more  conservative 
measures  have  been  tried  and  have  failed. 

The  combination  of  the  postural,  dietetic,  and  medicinal  treatment,  with  abso- 
lute rest  under  strict  surveillance,  combined  with  compression  when  possible  upon 
the  cardiac  side  of  the  tumor,  and  when  this  cannot  be  done,  directly  upon  the 
tumor,  will,  in  the  majority  of  instances,  render  it  unnecessary  to  resort  to  opera- 
tion. Digital  compression  may  be  practiced  at  varying  intervals,  as  well  as  me- 
chanical, and  pain  can  be  relieved  by  infiltration  with  one  half  of  one  per  cent 
cocaine  solution.  The  adjustment  of  the  elastic  bandage  compress  is  perfectly 
feasible,  and  has  been  used  successfully.^ 

'  See  classical  paper  by  Prof.  Edmond  Souchon,  of  New  Orleans,  "Annals  of  Surgery,"  No- 
vember and  December,  189.5. 

^  A  baseball  pitcher,  twenty-five  years  old,  developed  an  aneurism  invohnng  the  third  portion 
of  the  right  subclavian  and  the  axillary  artery.  A  large  pulsating  tumor  was  distinctly  recognized, 
extending  from  about  one  inch  above  the  clavicle  into  the  axilla  and  for  about  three  inches  along 
the  axillary  artery.  Appreciating  the  dangers  of  tjing  the  subcIa\Tan  in  the  first  or  second  division 
the  patient  was  put  to  bed.  placed  upon  a  restricted  diet  of  nutritious  food  in  small  quantities  at 
frequent  intervals,  vnth  the  minimum  of  fiquids,  and  strict  attention  to  the  alimentary  canal. 
He  was  not  permitted  to  leave  the  bed,  but  was  allowed  to  sit  upright  or  recline  on  pillows.  The 
least  possible  motion  of  the  affected  arm  was  permitted.  Direct  compression  was  begun  by  means 
of  a  soft  ball  of  absorbent  cotton  laid  over  the  tumor  and  held  by  an  elastic  bandage,  with  only 
sufficient  pressure  to  hold  it  in  place  for  the  first  few  days.  This  was  grad\ially  tightened  until  it 
became  painful.     A  hollow  rubber  ball  was  substituted  for  the  cotton.     At  varying  intervals  the 


106  ANEURISMS 

Aneurism  of  the  hrachial,  radial,  and  ulnar  arteries. 

Aneurism  of  the  brachial  arteiy  should  be  treated  by  compression  on  the  car- 
diac side  when  possible,  next  on  the  distal  side,  or  by  either  of  these  methods 
combined,  with  direct  compression  of  the  sac. 

In  applying  compression  directly  upon  or  on  the  distal  side  of  an  aneurismal 
sac,  the  possibility  of  rupture  and  htemorrhage  should  not  be  overlooked,  and  a 
tourniquet  (preferably  a  piece  of  rubber  tubing)  should  always  be  in  readiness 
to  be  tightened  on  the  cardiac  side  at  the  first  suggestion  of  this  accident. 

One  of  the  great  advantages  in  a  patient  trial  of  compression,  even  if  the 
ligature  should  ultimately  have  to  be  applied,  is  that  it  tends  to  develop  a  col- 
lateral circulation  and  thus  removes  the  chief  danger  of  gangrene,  when  occlusion 
occurs  either  from  consolidation  in  the  sac  or  the  ligature.  This  applies  with 
especial  force  to  single  vessels,  as  the  brachial  or  femoral. 

What  has  been  said  of  tlie  brachial  applies  in  equal  measure  to  the  radial  and 
ulnar  arteries.  Here,  however,  since  there  are  two  vessels  of  small  size,  the  ligature 
is  advised.  Either  of  these  can  be  tied  with  cocaine  anesthesia;  in  fact,  the  con- 
ditions are  rare  when  any  of  the  large  arteries,  with  the  exception  of  the  innomi- 
nate, first  portions  of  the  subclavian,  and  the  iliacs  may  not  be  exposed  and  the 
ligature  a2iplied  with  perfectly  satisfactory  cocaine  analgesia.^ 

Aneurism  of  the  vertebral  artery  is  very  rare,  and  is  almost  always  caused  by 
a  penetrating  wound.  It  may  be  mistaken  for  carotid  aneurism.  If  the  head  be 
flexed  upon  the  chest,  completely  relaxing  the  sterno-mastoid  muscle,  the  carotid 
artery  can  be  compressed  by  grasping  the  muscle  and  artery  between  the  thumb 
and  finger.  While  this  would  cause  pulsation  to  cease  in  a  carotid  aneurism,  it 
would  not  interfere  with  the  circulation  through  the  vertel:>ral,  which,  as  it  passes 
deeply  through  the  foramina  in  the  transverse  processes  of  the  cervical  vertebrse 
from  the  sixth  upward,  'cannot  be  compressed.  Although  the  deligation  of  this 
vessel  before  it  enters  the  foramina  of  the  sixth  cervical  is  a  very  difficult  opera- 
tion, it  should  be  undci'takcii  for  the  cure  of  aneurism.  Direct  compression  upon 
the  sac  incurs  a  very  idiisitli  rable  risk  of  death  from  embolism.^ 

Aneurism  of  the  inlcnial  mammary  and  of  the  intercostal  arteries  does  not 
demand  especial  consideration.  The  latter  occurs  occasionally  as  a  result  of  frac- 
ture of  the  rib.  They  may  be  readily  exposed  as  they  lie  in  the  groove  along  the 
lower  border  of  the  ribs. 

Aneurism  of  the  thoracic  aorta,  exclusive  of  the  arch,  does  not  come  within  the 
province  of  surgery.     The  method  of  Tufnell  is  advised. 

Aneurism  of  the  abdominal  aorta  is  most  frequently  met  with  near  the  dia- 
phragm. The  tuiaor  may  be  sacculated,  or  there  may  be  a  fusiform  dilatation  of 
the  entire  vessel. 

The  diagnosis  is  difficult,  unless  the  subject  be  thin  and  the  alimentary  canal 
emptied  so  that  palpation  and  auscultation  may  be  made  immediately  over  the 
tumor.  The  expansile  pulsation,  the  aneurismal  tremor  and  bruit,  together  with 
the  history  of  the  case,  should  lead  to  a  recognition  of  the  lesion. 

The  treatment  should  be  a  persistent  trial  of  the  postural  and  dietetic  method. 
As  a  last  resort,  the  introduction  of  steel  wire,  fine  watch-spring,  or  catgut  may 
be  tried. 

In  this  oi^eration  the  tumor  should  be  exposed  by  a  median  incision  and  the 
displacement  of  any  interposed  viscera.  A  small  trocar-canula  is  introduced  into 
the  sac,  the  trocar  withdrawn,  and  the  material  selected  is  rapidly  introduced  in 
quantity  about  equal  to  one  half  of  the  capacity  of  the  sac.  The  presence  of  the 
foreign  body  tends  to  cause  coagulation.     The  prognosis  is  exceedingly  grave. 

When  the  visceral  or  parietal  branches  of  this  vessel  are  involved,  if  the  char- 
acter of  the  lesion  cannot  be  recognized,   an  exploration  under  strict  asepsis   is 

bandage  was  loosened  and  digital  compression  was  made  upon  the  artery  where  it  passes  over  the 
first  rib.  When  this  and  the  liiechanical  pressure  could  no  longer  be  endured,  a  hypodermic 
of  morphia  or  instillation  of  cocaine  was  advised.  The  tumor  gradually  diminished  in  size,  the 
expansile  pulsation  was  less  noticeable,  the  mass  became  firmer  to  the  touch  and,  later,  became 
completely  solidified,  and  was  cured. 

1  The  author  has  tied  the  subclavian  in  its  third  surgical  division  with  this  anaesthetic^ 
^  This  artery  has  been  tied  here  by  Smyth,  Parker,  Alexander,  and  the  a,\itbor. 


ANEURISMS  107 

justifiable.  Deligation  upon  the  cardiac  side,  if  there  is  room,  or  if  not,  upon  the 
distal  side,  is  the  operation  of  election. 

Aneurism  of  the  common  iliac  arteries,  or  of  the  two  primary  divisions  of  this 
trunlc,  ma}-  be  diagnosticated  by  the  stethoscope,  combined  with  careful  palpation 
and  digital  exploration  by  the  rectum  or  vagina. 

The  mortalit}'  follo^ving  deligation  of  the  aorta  or  of  the  common  iliacs  for 
the  cure  of  aneurism  is  so  great  that  the  conservative  methods  heretofore  described 
should  be  first  persistently  emplo3'ed.  Mechanical  compression  with  the  horseslioe 
tourniquet  has  been  employed.  Digital  compression  of  the  aorta  under  spinal 
antesthesia  (cocaine)  may  also  be  advised.  This  may  be  done  through  a  small 
incision  in  the  linea  alba,  or  a  general  narcosis  lasting  from  one  to  two  hours 
may  be  substituted  if  necessary,  and  this  operation  may  be  repeated  at  intervals 
of  two  or  three  weeks  until  an  organized  coaguluni  is  secured. 

Ligation  of  the  abdominal  aorta  is  one  of  the  most  fatal  of  all  surgical  pro- 
cedures. Should  it  be  deemed  necessar}^  in  extreme  cases,  immediate  occlusion  hj 
the  ligature  should  not  be  attempted.  The  gradual  closure  of  this  vessel  should 
be  tried  by  surrounding  it  with  a  broad  animal  ligature,  which  would  reduce  the 
lumen  one  third.  After  an  interval  of  several  weeks,  a  second  ligature  at  a  point 
beyond  the  iirst  should  be  applied,  which  would  still  fvirther  but  not  completely 
close  the  vessel,  while  at  a  third  operation  an  attempt  at  final  occlusion  may  be 
made.  By  this  operation  it  is  intended  to  develop  a  collateral  circulation,  which 
would  lessen  the  strain  upon  the  final  ligature. 

In  iliac  aneurism,  situated  near  Poupart's  ligament,  compression  by  means  of 
a  hand  introduced  into  the  rectum  may  be  tried,  or  Davy's  lever  may  he  employed 
in  the  same  way.  Should  no  other  alternative  be  presented,  and  the  exterual  iliac 
alone  is  involved,  this  vessel  may  be  tied,  or  the  ligature  may  be  placed  upon  the 
common  iliac.  Aneurism  of  the  internal  trunk  is  amenable  to  treatment  by  com- 
pression of  the  common  iliac  or  by  deligation  of  the  primary  trunk. "^ 

Aneurism  of  the  branches  of  this  vessel  is  usuall}^  confined  to  the  gluteal  and 
sciatic,  and  results  from  a  severe  blow  or  a  penetrating  wound  of  this  region.  The 
author  successfully  operated  upon  a  case  of  aneurism  of  the  gluteal  by  cutting  down 
uj)on  the  tumor,  and  tying  this  vessel  Just  as  it  emerged  from  the  pelvis. 

Aneurism  of  the  superficial  femoral  artery  is  comparatively  frequent.  It  is 
usually  seen  in  the  upper  half  of  this  vessel,  and  almost  always  in  males.  As  the 
artery  is  superficial,  the  diagnosis  is  not  difficult,  since  the  expansile  pulsation  of 
the  tumor  can  be  readily  appreciated  hj  palpation  and  auscultation,  inspiration 
with  a  very  fine  hypodermic  needle  will,  if  necessary,  make  clear  the  diagnosj.s. 

Treatment. — Aneurism  of  the  femoral  artery  will,  in  the  vast  majority  of  cases, 
yield  to  judicious  and  patient  compression  combined  with  absolute  rest  in  bed  and 
restricted  diet.  Should  the  tumor  be  located  as  high  as  Poupart's  ligament,  the 
chances  of  siiccess  diminish,  since  pressure  will  have  to  be  applied  to  the  common 
or  external  iliac.  Under  such  conditions  direct  compression  by  means  of  Holmes' 
hollow  elastic  ball,  held  in  place  by  Esmarch's  bandage,  should  be  employed.  The 
pressure  should  be  very  gradually  increased.  Ligation  of  the  common  or  external 
iliac  should  never  be  done  until  after  a  long  and  patient  trial  of  the  more  con- 
servative methods,  and  when  there  is  a  choice  between  these  two  measures  the  ex- 
ternal iliac  should  be  selected." 

AVhen  the  timior  is  so  situated  that  compression  of  the  femoral  can  be  made 
at  or  below  the  rim  of  the  pelvis,  this  treatment  should  be  adopted.  Should  all 
conservative  measures  fail,  and  should  the  indications  be  not  clear  for  the  pro- 

'  Prof.  J.  D.  Bryant,  "Annals  of  Surgery,"  vol.  xvii,  189.3,  reports  the  cure  of  a  large  aneurism 
of  the  right  iliac  after  Macewen's  method.  Delicate  needles  were  introduced,  and  the  sac  teased 
by  drawing  the  point  of  the  needle  along  the  wall  of  the  aneurism  opposite  to  the  point  of  introduc- 
tion. The  teasing  lasted  about  half  an  hour,  and  two  of  the  needles  were  left  in  for  twenty-four 
hours. 

The  author  induced  coagulation  in  a  large  aneurism  of  the  ascending  arch  of  the  aorta  by 
this  method.  The  patient  died  very  suddenly  a  year  later  with  all  the  symptoms  of  cerebral 
embolism. 

^  It  would  be  safer  to  apply  the  distal  ligature  (after  the  method  of  Wardrop)  before  resorting 
to  ligation  of  the  common  or  external  iliac. 


108  ANEURISMS 

cedure  of  Matas,  the  ligature  becomes  necessary,  and  the  effort  should  be  made 
to  reach  the  artery  below  the  origin  of  the  profunda  femoris,  since  the  danger 
of  gangrene  is  greatly  lessened  if  this  collateral  route  be  left  open. 

The  treatment  of  aneurism  of  the  lower  portion  of  the  femoral  does  not  differ 
materially  from  that  advised  for  the  upper  portion. 

Aneurism  of  the  profunda  femoris  is  rare,  and  is  usually  the  result  of  a  punc- 
tured wound.  The  treatment  is  the  same  as  given  for  the  common  trunk.  In 
properly  selected  cases,  when  the  aneurism  has  been  recognized  early,  the  method 
of  Professor  Matas  may  be  employed.  The  technic  will  be  given  in  connection  with 
po2)liteal  aneurism. 

Aneurism  of  tlie  Popliteal  Artery. — This  vessel  is  frequently  the  seat  of  aneu- 
rism, caused  by  the  compression  to  which  it  is  subjected  in  extreme  flexion  of 
the  leg  on  the  thigh.  It  occurs  most  frequently  in  males,  and  in  the  active  period 
of  life — from  twenty-five  to  fifty  years  of  age. 

The  characteristic  symptoms  are  pain  due  to  pressure  on  the  popliteal  nerve 
and  the  posterior  surface  of  the  joint,  and  expansile  pulsation,  with  tlie  peculiar 
rushing  sound  of  the  blood  as  it  passes  through  the  sac.  The  differentiation  from 
glandular  enlargements,  exostoses,  or  overdistended  bursfe  may  be  made  by  digital 
compression  of  the  femoral  at  the  rim  of  the  pelvis,  which  will  cause  the  tumor 
to  diminish  in  size  and  pulsation  to  cease. 

In  abscess  of  the  popliteal  space  pain,  more  or  less  diffused  redness  and  swell- 
ing, with  the  usual  sympitoms  of  sepsis,  and  the  aljsence  of  pulsation,  will  exclude 
aneurism. 

Treatment. — If  conservative  measures  are  to  be  tried,  the  patient  should  rest 
in  the  recumbent  posture,  with  tlie  leg  of  tlie  affected  side  slightly  flexed.  The 
mattress  should  be  soft,  ajid  the  limb  held  in  a  comfortable  position  by  means  of 
a  pillow  beneath  the  popliteal  space.  Sand  bags  should  be  packed  on  either  side 
to  prevent  motion.  Mechanical  compression  should  be  applied  to  the  femoral, 
preferably  at  the  rim  of  the  pelvis  or  in  Scarpa's  space,  and  changed  from  place 
to  place  to  prevent  soreness. 

In  applying  pressure  it  is  not  intended  to  completely  occlude  the  artery,  and 
care  should  be  taken  not  to  comjiress  the  vein  which  lies  just  to  the  inner  side. 
The  elastic  bandage  and  a  small  rubber  ball  will  be  found  most  useful  in  carrying 
out  this  plan  of  treatment.  Should  tliis  fail,  one  of  two  operations  may  be  selected : 
viz.,  tying  the  vessel  below  the  origin  of  the  profunda  femoris,  at  Hunter's  canal, 
or  attempting  to  restore  the  integrity  of  the  artery  by  the  method-  of  Matas. 

Aneurism  beyond  the  popliteal  is  rare.  The  anterior  and  posterior  tibials  are 
deeply  situated,  and  direct  compression  is  difficult.  As  the  ligature  of  eitlier  one 
of  these  vessels  incurs  no  risk  of  gangrene,  it  should  be  advised.  Should  the  dor- 
salis  pedis  be  effected,  direct  compression  with  the  elastic  bandage  should  suffice. 

Arterio-vcnous  aneurism  usually  occurs  as  the  result  of  a  gunsJwt  or  punctured 
wound.  The  communication  may  be  direct  (aneurismal-varix,  Pig.  HI),  or  indi- 
rect (varicose-aneurism.  Fig.  146). 

As  a  rule,  the  vein  involved  becomes  dilated  and  tortuous,  and  pulsates  with 
each  systole  of  the  heart,  while  the  pulsation  in  the  artery  beyond  the  point  of 
communication  is  perceptibly  diminished.  Should  the  lesion  involve  a  single 
artery  and  vein,  as  the  femoral  or  brachial,  where  there  would  be  danger  of  gan- 
grene from  the  ligature,  the  member  should  be  rendered  bloodless  by  Esmarch's 
bandage,  a  careful  dissection  made  in  the  effort  to  separate  the  vessels,  and  to  close 
each  opening  by  the  finest  linen  sutures.  Should  this  be  impossible,  the  catgut 
ligature  should  be  applied  to  each  vessel  above  and  below  the  lesion. 


CHAPTEE    VIII 

WOUNDS    OF    THE    BLOOD    VESSELS LIGATION 

Wounds  of  arteries  and  veins  may  be  successfully  closed  by  sutures  as  well  as 
by  the  ligature,  and  under  certain  conditions  end-to-end  anastomosis  should  be 
performed.  The  dangers  are  considerable,  not  alone  from  hfemorrhage,  due  to 
failure  of  close  apposition  and  leakage  during  the  process  of  repair,  but  to  the 
possible  formation  of  a  thrombus  with  the  detachment  of  an  emljolus  (always 
disastrous  in  a  vein),  or  the  gradual  occlusion  of  an  artery  resulting  from  cell 
proliferation  and  the  deposit  of  fibrin  at  the  suture  line.  When,  however,  an  im- 
portant single  trunk  is  involved  (vein  or  artery),  as  the  vena  cava,  aorta,  either  of 
the  iliacs,  common  femoral,  popliteal  axillary,  and  brachial,  this  moie  heroic  pro- 
cedure is  entitled  to  trial.  The  same  is  true  after  division  of  the  two  ai'teries  of 
an  extremity.  In  one  instance  the  radial  and  ulnar  of  one  side  have  been  reunited 
and  the  circulation  successfully  reestablished. 

The  technic  requires  the  control  of  bleeding  by  digital  compression  or  by  a 
tape  one  fourth  inch  wide  twisted  and  held  by  forceps  just  tight  enough  to  occlude 
the  vessel  without  crushing  the  intima,  or  by  complete  local  exsanguination  with 
the  Esmareh  bandage.  Very  fine  and  perfectly  round  half-  and  quarter-curved 
needles,  the  finest  silk,  linen  (or  chromicized  catgut  No.  0)  are  required.  The 
animal  suture  has  the  advantage  of  being  absorbable  and  of  swelling  enough  to 
plug  the  needle  hole.  It  does  not,  however,  have  the  same  holding  power,  and 
this  fact  justifies  a  general  preference  for  linen  or  silk. 

If  the  wound  is  transverse  and  the  division  incomplete,  the  delicate  needle  and 
thread  should,  if  possible,  be  entered  on  one  side  one  sixteenth  inch  from  the 
edge,  and  made,  to  pass  through  the  adventitia  and  media,  and.  come  out  on  the 
cut  edge  between  this  and  the  intima,  and,  at  a  point  exactly  opposite  on  the 
other  end,  to  enter  between  these  coats  and  emerge  through  the  adventitia.  The 
sutures  should  not  be  more  than  one  sixteenth  inch  apart,  and  should  be  carefully 
and  evenly  adjusted  and  tied  in  equal  tension.  When  possible,  these  should  be 
reenforced  by  suture  of  the  sheath.  The  sheath  should  never  be  lifted  farther 
than  is  absolutely  necessary  for  fear  of  interfering  with  the  nutrition  of  the 
coats  (vasa-vasonmi).  When  the  conditions  do  not  favor  this  ideal  method  the 
sutures  may  be  carried  directly  through  all  the  coats.  The  intima  will,  in  all 
probability,  be  cut  through  in  the  act  of  tying,  and  the  suture  within  a  few  hours 
entirely  imbedded  in  a  mass  of  plastic  exudate  and  new  cell  proliferation. 

Should  the  wound  be  longitudinal  or  oblique,  the  same  technic  is  employed, 
but  when  a  considerable  portion  of  the  wall  is  destroyed,  end-to-end  suture  may 
be  required.  In  complete  division  (as  by  a  Irallet  wound)  trim  the  edges  smooth; 
arm  two  very  fine  needles  with  a  single  silk  or  linen  thread;  pass  one  needle  in 
a  direction  parallel  with  the  long  axis  of  the  upper  end,  entering  one  sixteenth 
inch  from  the  edge  and  coming  out  between  the  media  and  intima  on  the  cut 
edge.  Both  needles  are  now  carried  into  the  lumen  of  the  lower  end  for  one 
third  inch,  and  are  brought  up  through  all  the  coats  of  the  vessel  wall  one  six- 
teenth inch  apart  (Figs.  153,  153).  Two  other  similar  sutures  are  inserted  equi- 
distant. The  lower  end  is  now  split  at  one  point  in  its  long  axis  not  quite  to 
the  point  of  exit  of  the  twin  needles.  By  traction  on  the  sutures  the  upper 
end  is  invaginated  into  the  lower,  where  it  is  held  by  tying  the  threads.  The 
slit  is  closed  by  one  or  two  interrupted  stitches  and  the  rim  of  the  lower    (the 

109 


no 


WOUNDS  OF  THE  BLOOD  VESSELS— LIGATION 


outside)  segment  is  then  stitelied  in  four  or  five  places  to  the  adventitia  of  the 
upper  end,  taking  very  great  care  that  the  needle  does  not  penetrate  the  intima 
of  the  inner  segment.^  The  sheath  should  be  carefully  readjusted  and  stitched  by 
way  of  reenforcement,  and  the  wound  closed  with  all  aseptic  precautions. 


The  after-treatment  demands  the  greatest  watchfulness.  If  tlie  operation  has 
been  done  on  an  extremity,  this  should  be  kept  warm  with  cotton  batting,  and 
elevated  and  bandaged  to  diminish  the  blood  current  to  the  minimum  required 
to  maintain  nutrition. 

A  tourniquet  should  be  applied  ready  for  use,  and  the  eye  of  an  attendant 
kept  constantly  upon  the  dressing. 

For  fear  of  embolism,  suture  of  the  common  carotid  artery  should  not  be 
attempted.  Sutures  are  applied  to  the  veins  in  practically  the  same  way  as  to 
the  arteries.  The  danger  from  thrombosis  and  embolism  is  greater  than  in  arterial 
suture,  and  therefore  every  effort  should  be  made  to  so  insert  the  thread  as  to  leave 
no  portion  in  contact  with  the  blood  current  (Fig.  154).  Infolding  the  edges 
after  the  method  of  Lembert  should  be  attempted.  In  a  small  puncture  the  lateral 
silk  ligature  should  be  preferred  (Fig.  155),  as  it  is  practically  safe.  In  the  treat- 
ment of  arterio-venous  aneurism  favorably  located,  the  foregoing  technic  may  also 
be  applied. 

The  Surgical  Occlusion  of  Arteries  and  Veins. — In  order  of  preference  in  the 
permanent  occlusion  of  an  artery  or  vein  is  the  ligature,  torsion,  crushing,  and 
the  actual  cautery.  Ligatures  are  absorbable  (catgut,  plain  or  chromicized)  and 
non-absorbable  (linen  and  silk).  (Silkworm  gut  or  kangaroo  tendon  are  only 
used  for  sutures.)  Plain  catgut  of  proper  size  is  employed  almost  to  tlie  exclu- 
sion of  all  other  ligature  material..  It  is  usually  applied  as  a  single  strand,  although 
in  tlie  deligation  of  a  very  large  vessel  (as  the  aorta  or  innominata)  where  a 
broader  distribution  of  pressure  may  be  required,  a  iroad  ligature  may  be  made 
of  six  or  a  dozen  medium-sized  threads  arranged  parallel  or  very  loosely  twisted. 
Occasionally  where  the  process  of  repair  may  be  delayed  (as  in  an  infected  area) 
the  ten-day  chromic-acid  catgut  may  be  substituted. 

Linen  or  silk  are  never  necessary  in  tying  an  artery,  but  for  the  lateral  liga- 
ture of  a  vein  that  has  been  punctured  or  is  bleeding  from  a  collateral  branch 
severed  close  to  the  parent  trunk,  fine  linen  is  invaluable.  They  are  much  less 
apt  to  slip  than  the  softening  animal  material,  and  in  certain  dissections,  as  along 
the  jugular  or  axillary  veins,  should  always  be  preferred   (Fig.  155). 

1  The  author,  while  without  actual  experience  in  this  new  and  brilliant  procedure  of  Prof. 
John  B.  Murphy,  is  of  the  opinion  that  the  danger  from  this  through  and  through  suture  is  over- 
estimated, as  has  already  been  proven,  in  intestinal  suture. 


WOUNDS  OF  THE  BLOOD  VESSELS— LIGATION 


111 


In  tying  an  artery  either  in  continuity  or  near  the  end  of  a  divided  vessel, 
the  plain  reef-knot  is  usually  j^referred  for  the  reason  that  the  degree  of  ten- 
sion in  the  first  knot  can  be  more  accurately  determined.  In  almost  all  instances 
this  will  hold,  hut  should  it  slip  or  yield  it  may  be  firmly  held  by  the  suture 
forceps  especially  designed  for  this  purpose.  A  second  and  a  third  knot  should 
always  follow  in  using  an  animal  ligature  or  suture. 

When  the  vessel  to  be  secured  is  so  deeply  situated  that  the  suture  forceps 
cannot  be  used  the  double  or  friction  knot  may  be  substituted. 

While  the  occlusion  of  an  undivided  artery  may  result  from  a  ligature  so 
loosely  applied  that  the  opposing  surfaces  of  the  intima  are  barely  held  in  con- 
tact, it  is  always  advisable  to  use  force  enough  with  the  first  knot  to  crush  the 
fragile  intima  and  media.  Imbedding  the  ligature  in  this  way  is  always  required 
to  prevent  slipping  when  the  exposed  stump  of  an  artery  is  tied.  The  strong 
connective-tissue  layer  (adventitia)  will  prevent  accident  until  permanent  occlu- 
sion results  from  cell  proliferation  in  the  process  of  repair.'^ 

Torsion,  in  which  the  end  of  an  artery  is  seized  by  a  forceps  and  twisted 
several  times  on  its  axis,  crushing  the  intima  and  media  and  spinning  the  con- 
nective tissue  of  the  outer  coat  into  a  loosely  twisted  thread,  is  useful  especially  in 

arresting  hsemorrhage  from  small- 
er vessels  (arterioles,  etc.),  when 
haste  is  necessary.  In  an  emer- 
gency it  may  be  applied  to  vessels 
as  large  as  the  femoral  or  brachial. 


vx 

"^^ 

/ 

A3,_  ■_._. 

Fig.  154.— (After  Bickham.) 


Fig.  155.— (After  Bickham.) 


Crushing  with  the  angeiotribe,  with  or  without  the  addition  of  the  actual 
cautery  is  occasionally  emplo3'ed  in  tlie  division  of  vascular  pedicles  (tubes,  ovaries, 
etc.),  though  more  expeditious  than  the  ligature,  silk,  linen,   or  strong  ehromi- 

'  In  188.3,  in  experiments  upon  animals,  the  author  demonstrated  that  when  under  aseptic 
conditions  an  animal  ligature  was  applied  to  an  artery  in  continuity  in  such  a  way  that  opposing 
surfaces  of  the  intima  were  held  in  apposition  without  breaking  through  this  coat  or  the  media, 
an  active  cell  proliferation  was  precipitated  in  the  zone  of  hypcrEemia  which  followed  the  trau- 
matism, and  that  permanent  occlusion  resulted  from  the  fibrillation  (contraction,  cicatrization) 
of  this  new  formed  connective  tissue. 

This  result  prove<:l  the  correction  of  the  theory  previously  advanced  (but  not  demonstrated) 
that  the  clot  was  an  accident  of  and  not  an  essential  factor  in  arterial  occlusion.  In  other  words, 
that  the  process  of  repair  in  an  artery  did  not  differ  from  that  of  any  other  structure  under  corre- 
Bponding  conditions. 

Fig.  65  from  the  common  carotid  of  a  horse  shows  the  rich  cell  proliferation  of  the  intima 
and  adventitia  following  the  presence  of  a  broad  animal  ligature  which  did  not  quite  close  the 
lumen  of  the  vessel. 

Under  septic  conditions  the  result  is  ultimately  the  same  provided  that  infection  does  not 
cause  the  vessel  wall  to  break  down. 


112 


WOUNDS  OF  THE  BLOOD  VESSELS— LIGATION 


cized  catgut  is  Biore  deserving  of  confidence.  However,  this  method  is  still  in 
general  use  in  the  clamp  and  cautery  operation  for  hasmorrhoids. 

Tlie  methods  apijlied  to  arteries  may  be  used  as  well  in  the  closure  of  veins. 
In  order  to  prevent  the  influx  of  air  the  proximal  end  should  first  be  carefully 
secured,  especiallj'  in  operations  near  the  root  of  the  neck.  Even  the  vena  cava 
ascendens  has  been  successfully  deligated,  the  patient  four  years  later  being  able 
to  work  in  the  upright  posture  without  inconvenience. 

Ligation  in  Continuity. — In-  tying  an  artery,  while  the  incision  should  be 
along  tlie  line  of  the  artery,  it  should  lean  as  far  from  the  accompanying  vein  as 


possible.  In  approaching  the  vessel  after  the  skin  is  divided,  the  fascia  and  all 
intervening  tissues  sliould  be  grasped  between  two  long,  delicate  dissecting  for- 
ceps (Figs.  156,  157),  until  the  sheath  is  reached,  and  this  is  opened  in  the  same 
manner.  As  soon  as  the  wall  of  the  artery  is  exposed  the  sharp-pointed  instru- 
ments sliould  be  laid  aside.  A  dull-pointed  aneurism-needle,  or  a  flexible  silver 
probe,  should  now  be  passed  between  the  sheath  and  the  vessel,  and  carried  care- 


fully around  the  artery,  keeping  the  point  close  to  the  wall  of  the  vessel.  When 
a  nerve  or  vein  is  in  close  relation,  the  instru.ment  should  be  introduced  on  the 
side  nearest  these,  thus  insuring  their  exclusion.  The  dull-pointed  probe,  bent 
to  the  pioper  curve,  may  be  used  to  great  advantage  in  almost  all  operations  upon 
the  arteries.  After  the  point  is  carried  around  the  vessel  and  l^rought  up  out  of 
the  sheath,  the  ligature  may  be  tied  over  the  slight  bulbous  expansion  of  this  in- 
strument, which,  when  withdrawn,  leaves  the  ligature  around  the  vessel.  The 
force  employed  should  be  sufficient  to  occlude  the  vessel  and  prevent  slipping, 
yet  not  enough  to  inflict  unnecessary  violence  upon  its  walls.  The  single  reef- 
knot  should  be  preferred,  and  if  necessary  the  ligature  forceps  should  be  used  to 
hold  the  first  knot  while  the  second  is  being  tied.     In  using  animal  ligatures  a 


WOUNDS  OF  THE  BLOOD   VESSELS— LIGATION  113 

third  knot  should  always  be  made.  The  ends  should  be  cut  off  for  one  fourth 
to  one  half  of  an  inch  from  the  knot,  and  the  wound  closed  for  a  permanent 
dressing. 

Ligation  of  the  Innominate  Artery — Anatomy. — The  arteria-innominata  is  de- 
rived from  the  transverse  segment  of  the  arch  of  the  aorta,  immediately  ia  front 
of  the  trachea,  just  beliind  the  middle  of  the  stermmi,  at  a  level  varying  from 
one  half  to  one  and  a  half  inches  below  the  tipper  margin  of  the  manubrium. 

From  tliis  origin  it  travels  obliqueh'  upward,  backward,  and  to  the  right 
(crossing  the  trachea  from  its  center),  and  bifurcates,  near  the  upper  margin  of 
the  clavicle,  between  the  sternal  and  clavicular  origins  of  the  sterno-mastoideus 
into  the  carotid  and  sulclavian  arteries,  the  first  of  these  coming  from  its  anterior 
aspect,  the  last  a  direct  continuation  of  the  arch  of  the  innominate.  The  innonii- 
nata  in  rare  instances  originates  to  the  left  of  the  trachea-;  more  frequently  it  is 
given  off  before  it  reaches  the  windpipe.  As  a  rule,  it  is  longer  in  females  than 
in  males. 

In  twenty-eight  cases  in  which  I  measured  the  distance  of  the  origin  of  the 
innominate  from  the  commencement  of  the  aorta,  tlie  average  was  three  inches 
and  a  half.  In  tliirty-seven  measurements  made  to  determine  the  length  of  the 
innominate  artery,  the  average  was  one  inch  and  a  half,  the  shortest  specimens 
being  three  fourths  and  the  longest  two  inches. 

Operation. — Place  a  firm  cusliion  crosswise  beneath  the  shoulder-blades,  so 
that  the  head  will  fall  well  back,  and  thus  draw  the  artery  upward.  Have  an 
assistant  draw  tlie  arm  and  shoulder  of  the  right  side  forcibly  downward,  while 
the  chin  is  elevated  and  the  face  turned  slightly  to  the  left. 

With  the  patient  completely  anjesthetized,  and  every  arrangement  made  for 
expedition,  make,  from  the  center  of  the  interclavicular  notch,  an  incision  about 
three  inches  in  extent  along  the  clavicle.  A  second  incision,  commencing  at  the 
inner  border  of  the  sterno-mastoideus,  about  two  inches  and  a  half  above  the 
clavicle,  is  made  to  unite  with  the  first  incision  at  the  middle  of  the  interclavicular 
notch.  Dissect  the  flap  upward  until  the  sterno-mastoid  mttscle  is  exposed,  the 
sternal  and  two  tliirds  of  the  clavicular  origins  of  which  sliould  be  divided  upon  a 
grooved  director  carefully  introduced.  Superficial  to  the  muscle  some  small  veins 
will  be  found,  and  underneath  its  clavicular  portion  is  the  iunction  of  the  sitb- 
clavian  and  jugular  veins,  in  dangerous  proximity.  The  anterior  jugular  veins 
will  be  seen  immediately  beneath  the  muscle,  and  should  be  tied  and  divided.  Dis- 
secting carefully,  with  the  handle  of  the  scalpel,  the  connective  and  areolar  tissue 
in  which  these  veins  are  imbedded,  the  origins  of  the  sterno-hyoid  and  sterno- 
thyroid muscles  will  be  reached,  and,  when  these  are  divided  carefully  upon  the 
director,  the  right  carotid  will  be  seen  near  the  center  of  the  wound.  Following 
this  down,  the  arteria  innominata  will  be  found  just  behind  the  sterno-clavicular 
artictilation  (Fig.  158).  Being  exposed  with  the  scalpel-handle,  or  any  dry  dis- 
sector not  likely  to  wound  the  vessel,  tlie  aneurism-needle  should  be  passed  from 
right  to  left  behind  the  artery,  care  being  taken  to  avoid  wotmding  the  right  vena 
innominata  and  the  pneumogastric  nerve,  or  puncturing  the  pleura,  in  which  the 
artery  is  partly  imbedded.  It  is  well  to  bear  in  mind  that  the  left  innominate 
vein  crosses  this  artery,  although  usually  verj^  low  down.  When  the  aorta  is  situ- 
ated low  in  the  thorax,  it  may  be  necessary  to  remove  the  sternal  end  of  the 
clavicle  and  a  segment  of  the  sternum. 

An  element  of  danger  in  this  operation  is  the  origin  of  an  abnormal  branch 
from  the  innominate.  In  thirt\'-four  consecutive  subjects  which  I  examined  as 
to  this  feature,  I  found  an  abnormal  branch  to  be  derived  from  the  innominate 
in  five.  When  the  necessity  for  occlusion  of  the  arteria  innominata  arises,  and  the 
conditions  are  such  as  to  permit  it,  the  following  method  should  be  followed:  The 
right  common  carotid  should  first  be  tied  one  inch  above  its  origin.  By  a  careful 
dissection  the  first  di^-ision  of  the  sttbclavian  and  its  branches  should  then  be 
exposed,  drawing  the  internal  jugular  to  the  outer  side  until  the  vertebral  is 
secured.  Avoiding  the  phrenic  nerve,  as  it  descends  to  the  inner  side  of  the  scale- 
nus anticus,  the  internal  mammary  and  branches  of  the  thyroid  axis  should  be 
secured,  and  finally  a  ligature  of  large,  smooth  catgut,  placed  around  the  sub- 


114 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


clavian  artery,  aboiit  the  middle  of  its  iirst  portion.  A  careful  study  of  the 
anatomy  and  surgery  of  this  region  leads  me  to  conclude  that  this  procedure, 
though  difficult  of  execution,  oiiers  a  better  prospect  of  success  than  deligation  of 
the  larger  and  primitive  trunk,  nearer  the  heart. 


-Showing  the  relations  of  the  parts  inA'olved  in  deligation  of  the  innominate  artery;  the  right 
subclavian  and  carotid  in  their  first  divisions. 


Ligation  of  the  Common  Carotid  Arteries  and  the  Internal  Jugular  Vein — 
Anatomy. — In  one  hundred  and  twenty  dissections  I  found  the  common  carotid 
artery  to  bifurcate  on  a  level  with  the  notch  between  the  two  alte  of  the  thyroid 
cartilage  in  one  hundred  and  sixteen.  Tlie  anomalies  of  this  vessel  are  so  rare 
that  they  do  not  deserve  mention  ia  this  Trork. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


115 


Operation. — A  firm  cushion  should  be  placed  under  the  shoulders  and  lower 
part  of  the  neck,  with  the  chin  elevated,  and  the  face  turned  in  the  direction  away 
from  the  side  upon  which  the  operation  is  to  be  performed.  A  line  extending 
from  the  tragus  of  the  ear  to  the  sterno-clavieular  articulation  will  cover,  and  be 


Fig.  159. — Showing  lines  of  incision  and  relation  of  parts  involved  in  deligation  of  the  common  carotid, 
above  and  below  the  anterior  belly  of  the  omo-hyoid,  and  the  external  carotid  below  the  lingual  and 
above  the  facial. 


parallel  with,  the  internal  and  common  carotid  arteries  in  their  surgical  length. 
This  line  will  strike  the  center  of  bifurcation  of  the  primitive  carotid  almost  in- 
variably on  a  level  with  the  upper  border  of  the  thyroid  cartilage,  and  the  anterior 
edge  of  the  sterno-mastoideus  from  one  inch  and  a  quarter  to  one  and  a  half  below 


116 


WOUNDS  OF  THE  BLOOD  VESSELS— LIGATION 


this  level.    The  point  of  election  is  about  one  inch  below  this  bifurcation,  and  at 
the  upper  border  of  the  anterior  belly  of  the  omo-hyoid  muscle. 

The  incision,  being  made  with  its  direction  as  above  given,  its  center  about  one 
inch  below  the  bifurcation,  extending  from  one  and  a  half  to  two  inches  above  and 


Fig.  160. — Showing  the  relations  of  parts  involved  in  deligation  of  the  left  carotid,  at  the  root  of  the  neck, 
and  the  left  subclavian  in  its  first  surgical  division. 

below  this  point,  will  divide  first  the  integument,  and  with  this  the  thin  platysma 
myoides,  some  filaments  of  the  superficiaUs  colli  nerve,  of  no  importance,  and  some 
small  veins  passing  from  the  anterior,  either  to  the  internal  or  external  jugular 
veins.     About  the  center  of  the  wound  the  edge  of  the  mastoideus  will  be  seen. 


WOUNDS  OF   THE   BLOOD   VESSELS— LIGATION 


117 


and  below  this   (usually)  the  anterior  belly  of  the  omo-hyoideits  (Fig.  159,  lower 
half).     The  sheath  of  the  carotid  and  jugular  vein  is  now  exposed,  often  crossed 


,4iil 


Fig.  161. — Shon-mg  the  relations  of  the  important  organs  at  the  root  of  the  neck,  and  apex  of  the  thorax. 
Frozen  horizontal  section  at  the  level  of  the  third  dorsal  vertebra.  (After  Braune.)  1,  Innominate. 
2,  Left  carotid.  3,  Left  subclavian.  4,  Right  subcla\'ian  arteries.  5,  6,  Left  and  right  irmominate 
veins.  7  and  8,  Subclavian  veins.  9,  Inferior  thyroid  vein.  10,  Trachea.  11,  CEsophagus.  12, 
Spinous  process  of  second  dorsal  vertebra,     a  a,  Pneumogastric  nerves,     b,  Phrenic  ner\^es. 


by  the  thyroid  veins,  and  the  cervicalis  descendens  artery,  the  descendens  noni 
nerve  almost  invariably  lying  upon  the  center  of  the  sheath,  being  parallel  with 


118 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


the  axis  of  the  common  and  internal  carotids.  In  two  instances  I  have  seen  the 
superior  thyroid  artery  turn  directly  down,  in  front  of  the  common  trunk,  for  an 
inch  or  more,  and  then  turn  abruptly  inward  to  be  distributed  to  the  thyroid 
body.  Under  such  abnormal '  conditions  this  vessel  would  probably  be  divided. 
The  communicans  noni  is  occasionally  found  crossing  the  sheath  from  without 
inward,  to  anastomose  with  the  descendens.  These  nerves  will  be  drawn  to  the 
outer  or  inner  side  of  the  wound,  as  is  most  convenient.  The  sheath  should  be 
opened  on  its  tracheal  side,  as  far  as  possible  from  the  jugular  vein,  and  the  needle 
passed  from  without  inward,  being  kept  close  to  the  artery  in  order  to  avoid 
wounding  the  vein  or  including  the  pneumogastric  or  sympathetic  nerves.  The 
sheath  should  be  well  opened,  and  the  artery  clearly  exposed,  so  that  the  needle 
may  be  manipulated  with  more  of  certainty  and  less  danger  from  tliese  too  com- 
mon and  unfortunate  accidents.  In  several  instances  the  artery  has  been  transfixed ; 
the  jugular  has  been  wounded;  the  pneumogastric  or  sympathetic  nerves  included 
in  the  ligature,  for  want  of  precision  in  separating  the  artery  from  the  vein. 
Certainly  the  danger  of  slough  in  the  artery  is  not  so  great  as  the  dangers  above 
enumerated.  Just  as  the  needle  is  being  introduced,  pressure  above  upon  the  vein 
would  empty  it  of  blood,  and  of  course  diminish  the  danger  of  wounding  it. 


Fig.  162. — Horizontal  section  at  tlie  \e\-e\  of  tlie  seventli  cer\-ical  vertebra.  1,  1,  The  riglit  and  left  com- 
mon carotid  arteries  and  the  internal  jugular  veins.  2,  The  right  and  left  vertebral  arteries  and  veins. 
Directly  between  the  vertebral  and  carotid  arteries  is  seen  the  sympathetic  nerve  and  the  inferior 
thyroid  artery  and  some  of  its  branches.  The  pneumogastric  nerves  are  seen  between  and  slightly 
posterior  to  the  internal  jugular  veins  and  the  common  carotids.  3,  Trachea.  4.  CEsophagus.  5, 
Transversalis  colli  artery  and  veins  and  descending  branches  of  the  subclavian  arterj'.  6,  Cords  of 
brachial  plexus.     7,  7,  External  jugular  vein.      (After  Braune.) 

The  operation  of  tying  the  carotid,  just  lielow  or  Ijehind  the  omo-hyoid,  is  prac- 
tically the  same  as  that  just  described  (Fig.  1-59). 

In  order  to  secure  this  vessel  at  the  root  of  the  neck,  an  incision  should  he  made 
in  the  carotid  line,  extending  from  the  sterno-clavicular  articulation  upward  a 
distance  of  three  or  four  inches,  and  between  the  two  heads  of  origin  of  the  sterno- 
mastoid  muscle.    This  will  divide  the  integument,  superficial  fascia,  platysma,  and 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


119 


deep  fascia,  and  some  descending  superficial  nerves.  The  fibers  of  the  sterno- 
mastoid  may  be  separated  and  lield  to  either  side  by  retractors.  Immediately 
beneath  it  will  be  found  the  anterior  jugular  vein,  and  some  small  branches  empty- 
ing into  it.     If  not  easily  displaced,  they  should  be  secured  with  a  double  liga- 


TiG.   163. — The  usual  relation  cf  the  contents  of  the  surgical  triangles  of  tlie  neck. 

dissections. 


From  the  author's 


ture,  and  divided  between  the  threads.  The  fillers  of  the  sterno-hyoid  or  sterno- 
thjToid  muscles  should  next  be  divided  on  a  grooved  director,  and  turned  aside 
or  separated  in  the  line  of  the  artery.  The  vessel  will  be  seen  deeply  situated  in 
the  line  already  given.  The  ligature  should  be  passed  from  the  outer  side.  Or 
an  L-shaped  incision,  similar  to  that  made  for  deligation  of  the  innominate  (Fig. 
158)  may  be  made,  and  the  carotid  found  by  separating  the  sternal  tendon  of  the 
mastoideus  muscle  and  turning  this  outward.     For  the  left  carotid,  see  Fig.  160. 


120 


WOUNDS  OF  THE  BLOOD  VESSELS— LIGATION 


The  approach  to  the  vesssel  in  this  region  should  be  very  cautious,  especially  upon 
the  left  side  of  the  neck,  since  the  internal  jugular  vein  crosses  from  the  outer 
to  the  inner  side  by  the  front.  On  the  right  side  the  vein  is  a  little  more  ex- 
ternal. The  pneumogastric  nerve  lies  behind  and  to  the  outer  side  of  the  artery, 
while  the  inferior  th}Toid  artery  and  sympathetic  nerve  are  more  deeply  situated. 
The  aneurism-needle  should  be  passed  around  the  artery,  from  the  outer  toward 
the  inner  side. 

In  the  "  Prize  Essay "  of  the  American  Medical  Association  for  1878  I  col- 
lected histories  of  seven  hundred  and  eighty-nine  cases  in  which  the  common  carot- 
id artery  had  been  tied  for  all  causes,  of  which  three  hundred  and  twenty-three, 
or  forty-one  per  cent,  died.  The  death-rate  will  never  again  reach  this  alarming 
figure. 

Thirtj^-four  cases  are  on  record  in  which  both  trunks  were  tied,  of  which 
twenty-five  recovered.^ 

Ligation  of  the  Internal  Carotid  Artery — Anatomy. — ^This  vessel  is  a  direct 
continuation  of  the  .common  trunk,  and,  while  straight  in  its  lower  portion,  it 
becomes  slightly  tortuous  as  it  approaches  the  carotid  canal.  An  abnormal  branch 
was  found  to  be  derived  from  its  first  portion  in  seven  of  one  hundred  and  twenty 
dissections. 

Operation. — The  position  is  the  same  as  for  tying  the  common  trunk.  The 
incision  should  be  made   in  the  carotid  line,  with  its  center  from  one  half   to 


-Relation  of  the 


to  the  carotids,  riglit  side.      (Life  size.) 


three  quarters  of  an  inch  above  the  upper  border  of  the  thyroid  cartilage.  The 
same  structures  will  he  divided  superficially,  and  the  veins  will  he  seen  superficial 
to  the  artery.  As  sho\vn  in  C,  Fig.  164,  they  may  cross  the  internal  carotid  almost 
at  a  right  angle,  or  (as  in  ^1  or  B)  they  may  empty  into  a  single  trunk,  and 
run  parallel  with  the  external  carotid.     This  last  is  the  most  usual  way,  but  it 

'  Op.  cit.     See  also  Riegner's  case,  "Centralblatt  fijr  Chirurgie,"  No.  26,  1884. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


121 


will  be  scarcely  possible  to  ligate  the  internal  carotid  without  ligature  and  division 
of  some  of  these  veins.  The  descendens-noni  nerve  will  be  seen  running  along  the 
arter}^  the  hypoglossal  crossing  it  about  one  inch  from  the  bifurcation.  The  vessel 
being  exjiosed,  the  needle  is  introduced  on  the  outer  side,  avoiding  the  jugular 
vein  and  pneumo gastric  nerve  externally,  the  external  carotid  internally,  and  the 
hijpoglossal  nerve  superficialh'.  The  pharyngea  ascendens  is  in  intimate  relation 
to  the  internal  carotid,  running  parallel  with  it  on  its  inner  aspect.  Occasionally 
tlie  first  cervical  ganglion  of  the  s}Tnpathetic  extends  as  low  as  this  point.  It 
will  be  avoided  by  keeping  the  needle  close  to  the  artery. 

Ligation    of   the  External   Carotid  Artery. — From   the   extensive   distribution 
of  its  branches  to  the  exposed  portions  of  the  neck  and  face,  the  external  carotid 

Anterior  temporal. 


■  temporal. \>^9 


Occipital. 


Sterno-mastoid. 


Transverse  facial. 


Internal  maxillary. 


Parotid  branches. 


Ascending  palatine. 


--    Facial. 

Lingual. 
V  -  Hyoid  branches. 

-^      --    Superior  thyroid. 

Descending  cervical. 


-The  external  carotid  and  its  branches.     The  average  arrangement  of  one  hundred  and  twenty- 
one  dissections  by  the  author.     (Life  size.) 


artery  demands  a  more  careful  consideration  than  any  single  vessel  of  the  human 
body. 

Anatomy. — Leaving  the  common  trunk  at  the  upper  border  of  the  thyroid  car- 
tilage, well  forward  of  the  anterior  border  of  the  sterno-mastoid  muscle,  this  vessel 
arches  forward  and  upward  (its  concavity  looking  toward  the  lobule  of  the  ear) 
until,  on  an  average  of  .93  inch  above  the  bifurcation,  after  giving  off  the  facial 
branch,  it  turns  obliquely  upward  and  backward  to  a  point  opposite  the  insertion 
of  the  external  pterygoid  muscle  into  the  neck  of  the  condyle  of  the  lower  Jaw, 
where  it  terminates  by  dividing  into  the  temporal  and  internal  maxillary  arteries. 

Eight  regular  branches  belong  to  this  vessel.  On  its  anterior  aspect  arise  from 
below,  upward,  the  tliyroidea  superior,  lingualis,  maxillaris  externa,  and  maxillaris 


122 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


interna.     On  its  posterior  and  internal  aspect  the  pharyngea  ascendens,  and  pos- 
teriorly the  occipitalis,  awicularis,  and  temporalis. 

The  usual  arrangement  of  these  branches  is  seen  in  Fig.  165,  which  is  the  aver- 
age of  one  hundred  and  twenty-one  dissections.     Abnormal  deviations  from  this 


Fig.  166. — Unusual  arrangement  of  the  branches  of  the  external  carotid.  1,  The  lingual  and  facial  from  a 
common  origin.  2,  The  lingual,  facial,  and  superior  tliyroid  from  a  common  origin.  3,  Close  relation 
of  first  five  branches  to  each  other. 


relation  of  the  branches  to  the  parent  trunk  occur  occasionally,  and  types  of  these 
may  be  seen  in  Figs.  1G6  and  16T.  The  relations  of  the  veins  to  these  arteries 
are  shown  in  Fig.  164. 

Operation. — The  external  carotid  may  be  tied  at  any  point.  In  the  lower  half 
the  operation  is  the  same  as  for  ligature  of  the  internal  carotid  on  the  same  plane, 
except  that  the  external  carotid  is  usually  from  one  quarter  to  one  half  inch  nearer 
the  median  line  than  the  internal. 

For  the  upper  half,  i.  e.,  above  the  posterior  belly  of  the  digastric,  the  incision 
should  extend  from  the  lobule  of  the  ear  along  the  ramus  of  the  jaw,  down  to  the 
level  of  the  thyroid  cartilage.  Cutting  through  the  superficial  structures,  the  artery 
will  be  found  just  behind  the  posterior  belly  of  the  digastric  muscle. 

Above  this  level — that  is,  after  the  artery  enters  the  parotid  gland — it  is  so 
situated  that  it  should  not  Idc  cut  down  upon.  The  incision  would  involve  the 
facial  nerve,  causing  paralysis  of  the  muscles  of  expression.  In  malignant  disease 
of  the  parotid,  where  this  gland  is  removed,  the  vessel  may  as  well  be  secured  here 
as  not,  since  the  operation  itself  usually  destroys  the  facial  nerve. 

It  is  a  remarkable  fact  that,  notwithstanding  the  close  proximity  of  the  branches 
of  the  carotid,  in  a  large  number  of  instances  in  which  it  has  been  ligatured  with- 
out the  precaution  of  securing  immediate  collateral  branches,  there  has  not  followed 
a  secondary  haemorrhage. 

On  account  of  the  importance  of  maintaining  the  integrity  of  the  circulation 
to  the  brain,  ligation  of  the  common  carotid,  for  a  lesion  in  the  distribution  of  the 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


123 


external  carotid,  should  never  be  performed  when  a  sufficient  distance  remains 
between  the  lesion  and  the  bifurcation  of  the  common  trunk  to  allow  of  the  appli- 
cation of  the  ligature. 

Ligation  of  the  Superior  Thyroid  Artery — Anatomy. — This  branch  was  present 
in  every  instance  in  one  hundred  and  twenty-one  dissections.  It  originated  almost 
invariably  on  a  level  with  the  thyroid  notch.  In  one  of  twenty-five  cases  it  will  be 
found  to  have  a  common  origin  with  the  lingual,  or  the  lingual  and  facial.  See 
Fig.  166. 

Operation. — With  the  neck  in  the  surgical  position,  i.  e.,  with  the  head  thrown 
back  and  the  face  turned  to  the  opposite  side,  make  an  incision  two  inches  long, 
parallel  with,  and  one  fourth  of  an  inch  in  front  of,  the  carotid  line.  The  center 
of  this  incision  must  be  on  a  level  with  the  thyroid  notch.  Immediately  beneath 
the  skin  and  platysma  myoides  will  be  seen  the  thyroid,  lingual,  hyoid,  and  other 
veins,  which  may  assume  either  of  the  forms  or  relations  shown  in  Fig.  164,  A,  B, 
being  most  common.  These  being  tied  and  divided, 
the  artery  will  be  found  oi3posite  the  point  above 
indicated. 

The  thyro-hyoid  nerve  will  occasionally  be  seen 
passing  across  this  artery,  although  usually  nearer 
the  median  line.  The  external  laryngeal  passes  be- 
neath it. 

Ligation  of  the  Lingual  Artery — Anatomy. — From 
its  origin,  usually  opposite  the  cornu  of  tlie  hyoid 
bone,  it  ascends  obliquely  iipward  and  inward,  and 
is  superficial  until  it  passes  underneath  the  stylo- 
hyoideus  and  digastricus  (posterior  belly),  and  then 
more  deeply  behind  the  hyo-glossus. 

In  two  of  one  hundi-ed  and  twenty-one  cases  it 
originated  in  common  with  the  superior  thyroid,  and 
in  two  other  instances  with  this  vessel  and  the  facial. 
In  thirty-one  of  one  hundred  and  twenty-one  cases  it 
arose  from  a  trunk  common  to  it  and  the  facial,  being 
abnormally  associated  in  one  in  every  three  and  a 
half  dissections. 

Operation. — The  lingual  artery  may  be  secured 
either  below  the  digastric  or  above  this  point,  where 
it  passes  beneath  the  hyo-glossus. 

For  the  low  operation  make  an  incision  as  in  the 
case  of  the  superior  thyroid,  excejit  that  its  center 
should  be  opposite  the  os  hyoides.  The  artery  will  be 
found  in  the  lingual  triangle,  bounded  posteriorly  by 
the  external  carotid,  above  by  the  digastric  muscle, 
below  by  the  os  hyoides.  The  middle  constrictor 
muscle  is  behind  it;  the  platysma  myoides  in  front, 
and  under  this  the  veins  above  noted.  The  hypo- 
glossal nerve  is  usually  just  above  it  as  it  crosses  the 
carotid,  while  the  thyro-hyoid  branch  of  this  nerve 
crosses  the  artery  on  its  way  to  the  muscle  it  supplies. 

The  high  .operation  is  one  of  considerable  diffi- 
culty. The  face  should  be  well  turned  to  the  opposite 
side,  the  chin  elevated,  and  held  perfectly  immovable. 
Beginning  immediately  over  the  os  hyoides,  near  the  median  line  of  the  neck,  an 
incision  is  made  outward,  and  parallel  with  this  bone  as  far  as  the  great  cornu, 
where  it  is  curved  upward  to  the  angle  of  the  Jaw  (Fig.  153).  This  crescentie  flap 
is  turned  up,  and  with  it  the  sub-maxillary  gland,  in  a  groove  on  the  under  surface 
of  which  the  facial  artery  runs.  As  soon  as  the  hyoid  bone  is  exposed  it  should 
be  fixed  with  a  tenaculum  and  drawn  steadily  down.  The  posterior  belly  of  the 
digastric  will  now  be  seen  passing  obliquely  downward  and  forward  to  the  central 
tendon  in  the  hyoid  bone.     Passing  beneath  this  muscle,  and  superficial  to  the 


.     „n  enlarged  superior 
thyroid  artery. 


124 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


hyo-glossTiSj  is  seen  the  hypoglossal  nerve,  which  runs  parallel  with  and  above 
the  artery.  Depress  the  posterior  belly  of  the  digastric,  insert  a  director  be- 
neath the  posterior  fibers  of  the  hyo-glossns,  and  divide  these.     The  artery  will 


Fig.   168. — Ligation  of  the  right  subclavian  in  its  tliird  surgical  division;  the  facial  in  the  neck  and  the 
lingual  beneath  the  hyo-glossus  muscle. 

be  found   just   beneath  this  muscle,   resting  upon  the  middle  constrictor  of   the 
pharynx. 

The  ligation  of  this  artery  is  frequently  practiced  preliminary  to  excision  of 
the  tongue  for  malignant  disease,  and  occasionally  to  arrest  hfEmorrhage. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


125 


Ligation  of  the  Facial  Artery — Anatomy. — The  facial  artery  was  present  in 
one  hundred  and  twenty  of  one  hundred  and  twenty-one  dissections.  In  the  in- 
stance in  which  it  was  missing  its  facial  distribution  A\^as  taken  bj^  the  transverse 
facial  from  the  temporal,  and  its  cervical  by  branches  from  the  lingual  and  the 
external  carotid.  Its  origin  is  usually  about  one  fourth  of  an  inch  above  the  lingual. 
It  is  the  longest  branch  of  the  external  carotid.  In  thirty-one  of  one  hundred 
and  twenty  cases  it  arose  in  common  with  the  lingual,  and  in  two  instances  it 
was  from  a  trunk  in  common  with  this  artery  and  the  superior  thyroid. 

Operation. — In  its  cervical  distribution  this  vessel  will  require  to  be  tied  at  or 
near  its  origin  from  the  carotid.     The  incision  along  the  axis  of  the  carotid,  as 


Fig.  169.— Ligation  of  the  posterior  temporal  at  tlie  zygoma,  and  of  tlie  facial  upon  tlie  inferior  maxilla. 

given  before,  with  its  center  a  quarter  of  an  inch  above  the  hj^oid  bone,  will  lead 
to  the  facial.  The  posterior  belly  of  the  digasiricus  will  be  found  with  its  center 
usually  above  the  origin,  but  soon  crossing  the  artery.     The  ninth  nerve  is  just 


126  WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 

below.  For  lesion  of  this  vessel  in  the  face  it  can  be  readily  secured  as  it  crosses 
the  inferior  maxilla  in  the  depression  at  the  anterior  border  of  the  masseter^  (Fig. 
169).  Before  making  the  incision,  which  should  be  parallel  with  the  horizontal 
portion  of  the  inferior  maxilla,  the  skin  should  be  well  pulled  up  from  the  neck, 
so  that,  after  healing,  the  cicatrix  will  fall  below  the  jaw. 

Ligation  of  the  Ascending  Pharyngeal — Anatomy. — This  artery  was  derived 
from  the  external  carotid  in  one  hundred  and  eleven  of  one  hundred  and  twenty- 
one  cases,  and  from  the  internal  carotid  in  four  others.  It  usually  conies  off  at 
a  point  opposite  the  origin  of  the  lingual,  and  occasionally  from  the  bifurcation 
of  the  pimitive  carotid.    A  pharyngeal  branch  is  not  uncommon  from  the  occipital. 

Operation. — The  external  carotid  must  be  exposed  by  an  incision  the  center  of 
which  is  opposite  the  level  of  the  hyoid  bone.  The  vessel  will  be  seen  ascending 
between,  and  parallel  with,  the  external  and  internal  carotids. 

One  fatal  ease  is  recorded  from  haemorrhage  after  a  wound  of  the  ascending 
pharyngeal. 

Ligation  of  the  Occipital  Artery — Anatomy. — The  occipital  was  present  in  one 
hundred  and  twenty  of  one  hundred  and  twenty-one  dissections,  and  it  was  found 
to  be  opposite  the  facial  in  the  majority  of  cases.  In  the  subject  in  which  it  was 
missing,  a  large  branch  from  the  inferior  thyroid  (not  the  ascending  cervical)  took 
its  distribution.  Not  infrequently  the  posterior  auricular  or  a  pharyngeal  branch 
arose  from  this  vessel. 

Operation. — It  may  be  secured  near  its  origin,  or  behind  the  mastoid  process. 
For  the  low  operation,  make  an  incision  in  the  carotid  line,  the  center  of  which  is 
about  one  inch  above  the  thyroid  notch.  After  dividing  tlie  deep  fascia  the  hypo- 
glossal nerve  will  be  seen,  which,  if  followed  backward,  will  lead  unerringly  to  the 
artery,  underneath  which  it  winds.  The  posterior  belly  of  the  digastric  muscle 
will  usually  require  to  be  lifted  upward. 

Behind  the  mastoid  the  occipital  may  be  tied  where  it  passes  beneath  the  cranial 
attachment  of  the  sterno-mastoid  muscle  (Fig.  170).  From  one  half  to  three 
fourths  of  an  inch  behind  the  mastoid  process  an  incision  alDOut  two  inches  long 
should  be  made,  extending  upward  and  backward.  The  aponeurosis  of  tlie  sterno- 
mastoid  muscle  is  divided  on  a  director,  and  the  artery  exposed.  The  constant 
relation  of  this  vessel  to  the  groove  on  the  under  surface  of  the  mastoid  process 
will  serve  as  a  valuable  guide. 

Ligation  of  the  Posterior  Auricular — Anatomy. — In  eleven  of  one  hundred  and 
twenty-one  dissections  this  vessel  arose  from  the  occipital,  and  in  four  it  was  absent. 
Its  origin  is  usually  one  inch  and  four  fifths  above  the  thyroid  notch. 

For  anatomical  reasons,  in  lesions  of  this  artery  the  external  carotid  should  be 
tied,  just  above  the  posterior  belly  of  the  digastric,  between  its  origin  and  that  of 
the  occipital.  It  runs  under  the  parotid  gland,  is  crossed  by  the  facial  nerve,  and 
has  beneath  it  the  spinal  accessory. 

Ligation  of  the  Temporal  and  Internal  Maxillary  Arteries — Anatomy. — The 
temporal  and  internal  maxillary  arteries  begin  at  the  terminal  bifurcation  of  the 
external  carotid,  in  the  substance  of  the  parotid  gland,  at  an  average  distance  of 
two  inches  and  nine  tenths  from  the  thyroid  notch. 

Operation. — The  temporal  artery  may  be  secured  by  a  perpendicular  incision 
immediately  in  front  of  the  tragus  of  the  ear,  where  it  crosses  the  zygoma  super- 
ficially (Fig.  170).  For  lesions  of  this  vessel  above  the  temporal  fossa,  and  often 
in  wounds  in  this  region,  the  ligature  will  be  unnecessary,  since  direct  compression, 
b}'  means  of  the  knotted  banclage,  will  suffice.  When  either  this  artery  or  the 
internal  maxillary  are  wounded  in  the  substance  of  the  parotid  gland,  the  external 
carotid  shoidd  be  tied  at  the  posterior  belly  of  the  digastric.  The  same  procedure 
is  indicated  in  lesions  of  the  internal  maxillary,  in  its  deeper  portions. 

Ligation  of  the  Internal  Jugular  Vein. — The  intimate  relation  of  this  vein 
to  the  internal  and  common  carotid  arteries  renders  it  accessible  by  the  same  in- 
cisions laid  down  for  the  ligation  of  the  arteries.  The  vein  is  contiguous  to  the 
artery,  and  is  external  and  slightly  superficial  to  it.  On  the  left  side,  at  the  root 
of  the  neck,  the  jugular  comes  more  to  the  front,  while  on  the  right  side  it  tends 
to  the  outer  side. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


127 


The  rules  which  apply  to  the  ligation  of  arteries  apply  with  equal  force  to  the 
ligation  of  veins.  In  tying  the  internal  jugulars  the  aneurism-needle  should  be 
passed  from  the  inner  side.^ 

The  anterior,  external,  and  posterior  jugular,  and  other  veins  of  the  neck,  do 
not  demand  especial  consideration.     When,  in  operations  in  the  neck,  it  becomes 


Fig.  170.— Ligatiiin  of  the  oc-cijjital  hcliind  tljc  mastoid  prnccss  and  the  r..nini<in  temporal  near  the  zy- 
goma, also  showing  the  relations  of  tlie  facial  nerve  to  the  terminal  portion  of  the  external  carotid. 

necessary  to  divide  them,  a  double  catgut  should  be  applied,  and  the  vessel  divided 
between  the  two  ligatures. 

The  Subclavian  Arteries  and  their  Branches — Anatomy. — The  right  subclavian, 
larger,  shorter,  and  more  superficial  at  its  origin  than  the  left,  is  derived  from  the 
innominate  behind  the  origin  of  the  carotid,  alrout  the  level  of  the  upper  margin 
of  the  clavicle  (more  frequently  alwve  than  below  this  line),  behind  the  interval 
between  the  two  tendons  of  thi;  stcrno-mastoideus.  It  is  the  direct  continuation 
backward,  upward,  and  outward  of  the  arch  of  the  innominate,  and  is  continuous 
with  the  axillary  artery,  at  the  lower  edge  of  the  first  rib.  Its  average  length  is 
2.83  inches. 

1  See  Prof.  S.  W.  Gross's  admirable  article  in  "American  Journal  of  the  Medical  Sciences," 


128 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


The  left  subclavian,  derived  1.23  inch  beyond,  to  the  left  of,  and  more  deeply 
situated  in  the  thorax  than  the  innominate,  travels  almost  vertically  upward,  until 
it  mounts  above  the  upper  surface  of  the  first  rib,  when  it  curves  very  abruptly 
outward  and  downward,  passing  behind  the  scalenus  anticus  and  thence  to  the 
lower  edge  of  the  first  rib.     Its  length,  in  the  average,  is  3.74  inches. 


Scapulai  IS 
posterior 


IntercoRtalis 
supei  loi    S 


Mam.  int. 
Inter,  sup. 


.JArteri'ae  Coronariae 


Fig.  171. — Relation  of  the  great  vessels  to  each  other  at  their  origins  from  the  arch  of  the  aorta,  and  the 
relation  of  the  branches  of  the  subclavian  arteries  to  each  other.     From  the  author's  dissections. 


Each  subclavian  has  three  surgical  divisions.  The  first  division  of  the  right 
artery  is  from  its  origin  from  the  innominate  to  the  inner  border  of  the  scalenus 
anticus.  That  of  the  left  artery,  from  its  origin  at  the  arch  of  the  aorta  to  the 
inner  border  of  the  left  scalenus  anticus  (Fig.  171). 

The  second  and  third  portions  of  both  vessels  are  identical  as  regards  direction 
and  relation,  being  different  in  the  origins  of  their  respective  branches.  The  second 
surgical  division  of  each  is  entirely  to  the  inner  side  of  the  inner  border  of  the  first 
rib.  The  tliird  portion  rests  chiefly  on  the  upper  surface  of  the  first  rib,  and 
extends  from  the  outer  border  of  the  scalenus  anticus  to  the  lower  border  of  this  rib. 

The  first  portion  of  the  riglit  subclavian  varies  from  three  fourths  to  one  inch 
and  a  half  in  length,  the  average  length  being  1.15  inch. 

The  first  portion  of  the  left  artery  varies  from  one  inch  and  a  half  to  three 
inches,  the  average  length  being  2.06  inches. 

The  second  portion  of  the  right  subclavian  averaged  .58  inch,  the  same  division 
of  the  left  subclavian  being  .56  inch  in  length. 

The  third  portion  of  the  right  artery  is  a  little  less;  the  same  division  of  the 
left  subclavian  a  little  more  than  1.11  inch  in  length. 

Nine  important  branches  arise  directly  or  indirectly  from  the  subclavian  arte- 
ries: the  vertebral,  internal  mammary,  transversalis  colli,  suprascapular,  inferior 
thyroid,  cervicalis  ascendens,  superior  intercostal,  p-ofunda  cervicis,  and  posterior 
scapular. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


129 


The  right  vertebral,  the  branch  most  constant  in  origin,  arises  from  the  superior 
and  posterior  aspect  of  the  main  trunk  (Fig.  1T2)  and  passes  upward  to  the  verte- 
bral foramen,  in  the  sixth  cervical  vertebra;  at  times  to  the  fifth;  less  frequently 
to  the  fourth.  The  relation  of  this  branch  is  important.  In  the  vast  majority  of 
subjects  it  will  be  found  between  one  fourth  and  three  fourths  of  an  inch  to  the 
inner  side  of  the  inner  margin  of  the  scalenus  anticus. 

The  left  vertebral  (Fig.  171)  arises,  in  four  per  cent  of  cases,  from  the  aorta. 
In  most  subjects  it  will  be  found  within  three  fourths  of  an  inch  of  the  left  scale- 
nus muscle. 

The  internal  mammanj  artery  arises  at  the  inner  border  of  the  scalenus  anticus. 
It  is  occasionally  from  the  thyroid  axis.  The  phrenic  nerve  passes  usually  in  front, 
occasionally  behind  it.  Behind  the  costal  cartilages  it  runs  parallel  with  the  edge 
of  the  sternum,  about  half  an  inch  external  to  it. 

The  thyroid  axis  arises  also  just  within  the  scalenus.  The  inferior  thyroid 
branch  arises  from  the  axis,  in  almost  every  case  on  the  left  side.  On  the  right, 
in  twenty-six  cases  examined,  it  originated  from  the  innominate  in  three,  and 
directly  from  the  subclavian  in  three  instances.  It  passes  upward  (inclining  at 
first  a  little  inward)  until  it  arrives  at  a  point  between  the  third  and  seventh 
(incomjjlete)  rings  of  the  trachea,  where  it  turns  abruptly  inward,  going  behind 
the  common  carotid  and  jugular,  in  front  of  the  vertebral,  and  is  distribiited  chiefly 
to  the  lower  portion  of  the  thyroid  body. 

The  transversalis  colli  passes  outward  in  front  of  the  scalenus  muscle  and  the 
phrenic  nerve,  underneath  the  omo-hyoid,  and  in  front  of  or  between  the  cords 


Ascend/nc/  Cervical 


Transverse  Cervical 


Fig.  172. — Plan  of  the  right  subelavi 


artery  and  its  branches.     From  the  author's  dissections 
(After  Quain.) 


of  the  brachial  plexus,  and  is  distributed  to  the  trapezius  muscle,  sending  a  branch 
in  the  direction  of  the  posterior  border  of  the  scapula,  which  anastomoses  with  the 
posterior  scapular  artery;  and,  when  this  last  vessel  is  not  present,  this  descending 
branch  is  continued  along  the  border  of  the  scapula  to  anastomose  with  the  sub- 
scapular branch  of  the  axillary. 

The  suprascapular  artery,  intimately  associated  with  the  preceding,  travels  sud- 
denly downward  and  outward  from  its  origin  near  the  inner  edge  of  the  scalenus 
anticus,  passes  between  the  suiclavian  artery  and  vein,  in  front  of  the  phrenic 
nerve,  crosses  in  front  of  the  third  division  of  the  main  trunk,  and  goes  to  the 
suprascapular  fossa  under  the  protection  of  the  clavicle,  anastomosing  with  the 
dorsalis  scapulce  of  the  subscapularis.  It  gives  off  a  branch  (freqitently  wounded 
in  operations  in  this  vicinity)  which  passes  behind  the  sterno-mastoideus  and  along 
the  upper  border  of  the  manubrium.     (It  is  not  usually  mentioned.) 


130  WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 

The  right  superior  intercostal  artery  comes  from  the  second  division  of  the 
subclavian  in  almost  every  instance;  occasionally  from  the  first.  The  left  is  usu- 
ally from  the  first  division. 

The  posterior  scapular,  one  of  the  most  important  branches  of  the  subclavian, 
in  a  surgical  view,  since  it  must  be  in  dangerous  jDroximity  to  a  ligature  applied  in 
the  third  surgical  division  (not  given  in  many  standard  text-books,  except  as  an 
occasional  branch  of  this  artery),  was  present  in  thirty-six  of  fifty-two  dissections, 
or  sixty-nine  per  cent.  It  was  present  in  nineteen  of  twenty-six  on  the  rigid  side, 
and  in  seventeen  of  twenty-six  on  the  left.  In  twenty-three  of  the  thirty-six  cases 
in  which  it  was  present  it  was  derived  from  the  third  division;  in  the  remaining 
thirteen,  from  the  second  division,  close  to  its  outer  limit.  On  the  right  side 
seventy-four  per  cent  came  from  the  subclavian,  within  one  fourth  of  an  inch  to 
the  outer  and  inner  side  of  the  external  border  of  the  scalenus  muscle;  twenty-six 
per  cent  external  to  this. 

On  the  left  side  eighty-two  per  cent  were  within  one  fourth  of  an  inch  to  the 
outer  and  inner  side  of  the  line  dividing  the  middle  and  external  thirds  of  the  main 
trunk;  eighteen  per  cent  were  to  the  outer  side  of  this.  The  tendency  of  this  im- 
portant branch  is  to  originate  near  the  scalenus,  i.  e.,  within  one  fourth  of  an  inch 
of  its  outer  edge.  When  this  vessel  is  present  the  transversalis  colli  is  small,  and 
when  absent  the  descending  branch  of  the  transversalis  takes  its  distribution.  Pass- 
ing outward  behind  the  most  superficial  cords  of  the  brachial  plexus,  it  turns 
sharply  downward,  along  the  posterior  border  of  the  scapula,  to  anastomose  with 
the  subscapular  branch  of  the  axillary. 

Operation — The  Eight  Subclavian  in  its  First  Surgical  Division. — The  incisions 
are  the  same  as  for  the  arteria-innominata.  AVhen  the  sterno-hyoid  and  sterno- 
thyroid muscles  have  been  divided  on  the  director,  the  internal  jugular  vein  will 
be  seen  directly  in  front  -of  the  artery.  It  may  be  drawn  to  the  inner  side  (or  outer, 
if  more  convenient),  carefully  using  for  this  purpose  a  dull  retractor.  Care  must 
be  exercised  not  to  injure  the  pleura  which  rises  against  the  artery  in  deep  inspira- 
tion. A  dull-pointed  aneurism-needle  may  now  be  passed  around  the  vessel,  taking 
care  not  to  wound  the  subclavian  or  innominate  vein,  or  the  recurrent  laryngeal 
nerve.  The  vertebral,  internal  mammary,  and  branches  of  the  thyroid  axis,  should 
also  be  secured. 

The  conditions  which  will  justify  this  operation  will  rarely  occur,  yet,  when 
the  operation  is  demanded,  every  source  of  danger  from  hsemorrhage  should  be 
avoided.  The  necessity  of  securing  the  carotid  at  the  same  operation  must  be 
determined  by  the  operator.  I  am  of  the  opinion  tliat  it  is  safer  to  occlude  this 
vessel  also. 

Ligation  of  the  Left  Subclavian  Artery  in  its  First  Surgical  Division — Opera- 
tion.— From  a  point  on  the  clavicle  one  fourth  the  distance  from  the  center  of  the 
interclavicular  notch  to  the  acromion  process  commence  an  incision,  and  carry  it 
to  the  inner  border  of  the  sternal  tendon  of  the  mastoid  muscle.  From  the  inner 
extremity  of  this  line  carry  a  second  incision  for  three  inches  along  the  anterior 
border  of  the  stern  o-mastoideus.  In  dissecting  this  flap  lift  with  it  the  mastoid 
muscle  divided  upon  the  director,  then  divide  the  sterno-hyoid  and  thyroid  muscles, 
and  feel  for  the  pulsation  of  the  artery,  which  ascends  deeply  behind  and  a  little 
outside  the  sterno-elavicular  articulation.  The  internal  jugular  vein  will  be  drawn 
outward,  and,  passing  the  finger  along  the  inner  border  of  the  scalenus  muscle,  the 
artery  will  be  felt  to  pulsate.  The  thoracic  duct  usually  is  to  the  right  of  and  a 
little  behind  the  artery  opposite  the  upper  border  of  the  sternum.  On  a  level  with 
the  insertion  of  the  scalenus  it  arches  to  the  left,  crosses  in  front  of  the  subclavian, 
in  front  of  the  scalenus,  behind  the  internal  jugular,  and  curves  do's^Tiward  to 
empty  into  the  suiclavian  at  its  junction  with  the  jugular  to  form  the  left  innom- 
inate vein.  On  account  of  the  intimate  relations  of  the  thoracic  duct  to  the  left 
subclavian  artery  as  this  vessel  goes  behind  the  scalenus,  the  ligature  should  not 
be  attempted  close  to  this  muscle,  nor  should  the  dissection  be  carried  fully  to  the 
scalenus.  The  artery  should  be  tied  as  low  down  as  possible,  the  duct  being  less 
likely  to  be  injured  here,  since  in  passing  behind  the  aorta  it  is  deeper  than  the 
artery.    It  will  be  found  behind  and  to  the  right,  the  pneumogastric  in  front  and 


WOUNDS   OF   THE  BLOOD   VESSELS— LIGATION  131 

to  the  right,  the  left  vena  innominata  crossing  in  front,  while  the  pleura  is 
directly  behind. 

The  vertehral  and  other  branches  of  the  left  subclavian  are  in  such  proximity 
to  the  thoracic  duct  that  it  will  be  dangerous  to  attempt  to  tie  them  at  this  point. 

Ligation  of  the  Subclavian  Arteries  in  their  Second  and  Third  Surgical  Divi- 
sions— Operation. — The  procedure  is  essentially  the  same  on  the  two  sides.  Place 
the  shoulders  upon  a  cushion,  pull  downward  on  the  arm  of  the  side  to  be  operated 
upon,  and  turn  the  patient's  face  to  the  opposite  side.  Find  the  location  of  the 
scalenus  anticus,  as  in  the  preceding  operation.  Slide  the  skin  well  down  upon 
the  clavicle,  and  along  this  bone  make  an  incision  three  or  four  inches  in  length, 
commencing  one  inch  to  the  inner  side  of  the  scalenus  muscle  and  terminating  near 
the  anterior  edge  of  the  trapezius.  Allowing  the,  skin  to  resume  its  normal  rela- 
tions, the  incision  will  be  carried  above  the  clavicle.  Upon  a  director  divide  the 
outermost  of  the  clavicular  fibers  of  the  mastoid  mirscle.  The  internal  jugular 
vein,  seen  in  the  anterior  portion  of  the  wound,  will  be  carefully  drawn  to  the 
inner  side,  the  operator  keeping  well  above  the  Junction  of  this  with  the  subclavian, 
and  thus  avoiding  the  lymphatic  duct. 

A  prominent  plexus  or  group  of  veins,  viz.,  the  external  jugular,  transversalis 
colli,  and  suprascapular,  will  he  seen  traversing  the  wound,  coming  from  their 
respective  origins,  toward  the  subclavian,  near  the  jugular.  These  should  be  secured 
with  a  double  ligature,  and  divided  or  held  aside.  Dissecting  carefully,  the  supra- 
scapular and  transversalis  colli  arteries  will  be  observed  running,  in  general,  in  the 
direction  of  the  first  incision.  The  posterior  belly  of  the  omo-hyoid  may  be  found 
in  the  upper  margin  of  the  wound,  crossing  the  scalenus  at  about  a  right  angle. 
The  ti-ansversalis  colli  and  the  suprascapular  may  be  secured  or  held  to  one  side, 
the  finger  passed  along  the  scalenus  until  the  tubercle  on  the  first  rib  is  felt,  imme- 
diately behind  which  the  artery  will  be  found.  If  it  shall  have  been  determined 
to  tie  the  artery  in  its  second  portion,  the  scalenus  anticus  muscle  will  be  cut  upon 
a  director,  the  operator  being  careful  to  avoid  the  phrenic  nerve,  which  crosses 
the  muscle  in  front,  coming  from  above  downward  and  inward.  (It  is  between  the 
layers  of  the  sheath  of  this  muscle.)  The  ligature  is  next  passed  around  the  artery 
from  before  backward,  care  being  taken  not  to  wound  the  pleura. 

If  the  third  division  of  the  artery  is  to  be  secured,  the  part  of  the  above  opera- 
tion relating  to  the  division  of  the  scalenus  will  be  omitted.  The  nearest  cord  of 
the  brachial  plexus  must  be  carefully  excluded,  posteriorly  to  the  artery;  the  sub- 
clavian vein  in  front  and  below  (Fig.  168). 

Ligation  of  the  Vertehral  Artery — Operation. — Locate  by  pressure  the  carotid 
tubercle  (the  transverse  process  of  the  sixth  cervical  vertebra).  The  point  at 
which  the  artery  is  to  be  secured  is  one  inch  directly  below  this  bony  prominence, 
which  must  be  the  center  of  a  perpendicular  incision,  four  inches  in  length.  Com- 
mence the  incision  at  the  outer  border  of  the  sterno-mastoid  muscle,  where  the 
external  jugular  vein  crosses.  The  internal  Jugular  is  seen  and  drawn  inward. 
The  transverse  cervical  artery,  and  one  or  two  smaller  veins,  are  met  with  next, 
and  drawn  to  the  outer  side  of  the  woimd.  The  scalenus  anticus  muscle  is  now 
brought  into  view,  and  to  the  inner  side  of  this  a  depression  between  this  muscle 
and  the  longus  colli.  In  this  sulcus  the  artery  lies,  the  vein  being  in  front  of  it. 
In  my  case  I  had  to  tie  the  vein  with  a  double  ligature,  divide,  and  turn  the  ends 
aside  in  order  to  secure  the  artery. 

Ligation  of  the  Internal  Mammary — Operation. — This  vessel  may  be  secured, 
as  has  been  described,  close  to  the  parent  trunk,  or  it  may  be  tied  in  one  of  the 
intercostal  spaces.  In  the  third  or  fourth  space  make  an  incision,  about  two  inches 
in  length,  obliquely  from  without  inward  and  downward,  the  center  of  which 
should  be  about  half  an  inch  external  to  the  edge  of  the  sternum.  Divide  the 
fibers  of  the  pectoralis  major  and  the  intercostal  muscle,  and  clear  away  the 
tissues  with  a  blunt-pointed  instrument.  The  arter}-,  with  its  venae  comites,  will 
be  seen  in  front  of  the  fibers  of  the  triangularis  sterni,  which  separates  it  from 
the  pleura  on  the  right  and  the  mediastinum  on  the  left  side.  In  separating  the 
veins  from  the  artery,  care  should  be  taken  not  to  break  through  the  thin  structure 
between  the  vessel  and  the  cavitv. 


132 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


The  other  branches  of  the  subclavian  arteiy  do  not  require  especial  considera- 
tion. The  inferior  thyroid  is  often  tied  in  the  removal  of  goitre.  I  have,  in  six 
operations,  found  and  deligated  it  prior  to  ablation  of  a  bronchocele.  It  will  usu- 
ally be  seen  on  the  tracheal  side  of  the  common  carotid,  just  below  the  anterior 
belly  of  the  omo-hyoid. 

Ligation  of  the  Axillary  Artery— Anatomy. — This  artery  may  be  tied  at  any 
part  of  its  course.  On  account,  however,  of  the  difficulty  of  approach  of  that 
portion  beneath  the  pectoralis  minor,  it  is  usually  secured  in  the  axilla,  below  this 
point,  or  between  the  upper  margin  of  this  muscle  and  the  lower  border  of  the 
first  rib. 

Operation. — With  the  head  thrown  back  and  the  shoulders  elevated,  allow  the 
arm  to  remain  by  the  side  of  the  body.  About  two  inches  from  the  sternal  end 
of  the  clavicle,  and  half  an  inch  below  its  inferior  border,  carry  an  incision  out- 
ward, parallel  with  this  bone,  a  distance  of  from  three  to  four  inches.  This  in- 
cision may  divide  a  superficial  vein  which  passes  from  the  cephalic  over  the  clavicle. 
The  clavicular  fibers  of  the  pectoralis  major  and  the  costo-coracoid  membrane  are 
divided  upon  the  director.  The  axillary  vein  will  then  be  seen  in  the  anterior 
portion  of  the  wound,  lying  in  front  of  the  artery,  which  may  l^e  felt  to  pulsate, 
or  seen  just  external  to  it.  ]\Iore  external  still  may  be  seen  the  anterior  cord  of 
the  brachial  plexus,  while  in  the  lower  portion  of  the  wound  the  cephalic  vein 
crosses  over  to  empty  into  the  axillary,  below  the  clavicle.  Beneath  the  clavicle  the 
subclavius  muscle  may  be  seen.  The  needle  should  be  passed  from  before  back- 
ward. If  necessary,  a  second  incision  may  be  made,  beginning  in  the  center  of  the 
first  and  carried  in  the  direction  of  the  axilla. 

This  operation  is  somewhat  more  difficult  than  ligation  of  the  suhclavian  in  its 
third  division,  but  it  is  preferable.  An  incision  beginning  at  the  junction  of  the 
middle  and  outer  third  of  the  clavicle,  and  separating  the  deltoid  and  jJeetoralis 
muscles,  will  expose  the  commencement  of  this  vessel. 

Operation  Below  the  Pectoralis  Minor. — Shave  and  cleanse  the  axilla,  and  ex- 
tend the  arm  at  a  right  angle  to  the  bodv.     Divide  the  distance  between  the  two 


'  '  '     in'.'V„!(W.'ii:rtl.'i"  ''^''"'1% 


Fig.   173. — Ligation  of  the  axillarj'  in  its  lower  tlurd 


folds  of  the  axilla  into  thirds,  and  the  junction  of  the  anterior  and  middle  thirds 
will  indicate  the  position  of  the  artery.  On  this  line  make  an  incision  in  the  axis 
of  the  arm,  well  up  into  the  axilla.  Cutting  through  the  skin  and  fasciae,  the 
contents  of  this  space  will  be  seen.  The  vein  lies  internal  to  the  artery,  often 
overlapping  it,  and  should  be  drawn  carefully  backward.  The  median  nerve  overlies 
the  artery,  or  is  on  its  anterior  aspect,  and  should  be  dra-mi  forward  when  the 
needle  is  passed  from  behind  forward   (Fig.  173). 


■^OUXDS   OF   THE   BLOOD   VESSELS— LIGATIOX 


133 


Ligaiion  of  the  Brachial  Artery— Anat- 
omy.— This  arten'  lies  in  the  furrow  along 
the  inner  border  of  the  eoraco-brachialis  and 
biceps  muscles,  tending  more  and  more  to 
the  front  as  it  nears  the  ellx)w-joint.  In  the 
lower  half  or  three  fourths  of  its  course  it 
has  its  venEB  comites  on  either  side,  with  oc- 
casional communications  across  the  track  of 
the  artery.  The  median  nerve  crosses  it  by 
the  front,  from  the  outer  side,  on  its  way 
to  the  forearm,  while  the  basilic  vein  is  well 
to  the  inner  side.  As  this  rein  passes  up 
toward  the  axilla  it  pierces  the  deep  fascia, 
and  lies  on  the  inner  side  and  close  to  the 
artery,  joining  with  the  Tens  comites  to 
form  a  single  large  trunk. 

Operation. — A  line  drawn  from  the  junc- 
tion of  the  middle  and  anterior  thirds  of  the 
axillary  space  (as  above  given)  to  the  mid- 
dle of  the  elbow-Joint,  in  front,  will  pass 
over  the  brachial  artery  in  its  entire  length. 
The  place  of  election  is  the  middle  of  the 
arm.  At  this  point  make  an  incision,  three 
inches  in  length,  over  the  artery  and  in  its 
axis.  Dividing  the  skin  and  deep  fascia,  the 
white  cord  of  the  median  nerve  will  be  first 
seen,  on  the  outer  side  of  the  brachial,  over- 
lapping the  companion  vein  on  this  side. 
Just  internal  to  this  is  the  artery,  with  the 
other  accompam-ing  vein  and  the  basilic  in 
close  relation  (Fig.  171).  The  ligature 
should  be  passed  from  the  iimer  toward 
the  outer  side.  The  operation  above  this 
point  is  essentially  the  same.  In  the  lower 
third  of  the  arm  proceed  as  follows :  On  a 
level  with  the  condyles  of  the  htmierus,  and 
between  the  median  basilic  vein  and  the  ten- 
don of  the  biceps,  commence  an  incision, 
which  is  carried  upward  three  inches  in  the 
brachial  line.  Cutting  through  the  deep 
fascia,  the  artery  is  readily  found  to  the 
radial  side  of  the  median  nerve,  and  sur- 
rotmded  by  its  veins  (Fig.  1T6).  The  needle 
is  passed  from  the  iimer  side.  Occasionally 
the  brachial  artery  is  double,  while  more  fre- 
quently it  bifurcates  into  the  radial  and  ul- 
nar, at  a  varying  distance  above  the  elbow. 

Ligation  of  the  Ulnar  and  Radial  Arte- 
ries.— The  radial  artery  may  be  tied  imme- 
diately above  the  wrist,  or  in  the  upper 
third  of  the  arm. 

Operation  at  the  Wrist. — A  vertical  in- 
cision, one  inch  and  a  half  long,  is  made  in 
the  center  of  the  depression,  between  the 
otiter  border  of  the  radius  and  the  radial 
border  of  the  extensor  carpi  radialis  muscle. 
Immediately  beneath  the  deep  fascia  the  ar- 
tery will  be  observed,  with  its  vena  comites. 
from  which  it  is  separated  and  tied  (Fig.lTo) . 


■-1. — Ligation  of  the  brachial  near  the 
middle  and  the  lower  third. 


^^ 


^°'  r  JhIT^'P^'""  °f  ^^^  "l"'^'-  and 
radial  arteries  at  the  wrist. 


wiL\ndSl'eTaetet1t'S*'l°j'1^'^°fthe 
134  menial  at  the  bend  of  the  elbow. 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


135 


To  find  the  artery  in  tlie  upper  third,  draw  a  line  from  the  middle  of  the 
elbow-joint,  in  front,  to  the  styloid  process  of  the  radius.  Along  this  line  make 
an  incision,  about  three  inches  in  length,  avoiding  the  superficial  veins,  if  possible. 
Cutting  directly  down,  the  artery  will  be  found  between  the  supinator  longus  ex- 
ternally and  the  pronator  radii  teres  on  the  ulnar  side.  The  radial  nerve  is  well 
to  the  radial  side,  and  the  venae  comites  on  either  side  (Mg.  176). 


Fig.  177. — Dissection  showing  the  relation  of  the  right  common,  external  and  internal  iliac  arteries  and 
veins.     The  ureter  is  seen  crossing  the  iliac  near  the  bifurcation. 

The  ulnar  artery  may  be  tied  at  the  bend  of  the  elbow,  and  near  the  wrist.  _'As 
it  passes  beneath  the  pronator  radii  teres  and  flexor  muscles,  it  is  so  deeply  situ- 
ated that  an  attempt  to  deligate  it  here  is  not  Justifiable.  Above  this  point  it  may 
be  secured  b}^  a  downward  extension  of  the  incision  given  for  ligature  of  the  brachial 
at  the  bend  of  the  elbow  (Fig.  176). 

Near  the  wrist-joint  an  incision  shoiild  be  made  about  a  quarter  of  an  inch  to 

'  the  radial  side  of  the  tendon  of  the  flexor  carpi  iilnaris  muscle.     This  incision 

should  commence  one  inch  above  the  level  of  the  pisiform  bone,  and  extend  upward 


136 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


one  inch.  The  ulnar  nerve  will  be  seen  partly  concealed  by  the  tendon,  while  the 
artery  and  its  accompanying  veins  are  immediately  on  its  radial  side  (Fig.  175). 

Ligation  of  the  Intercostal  Arteries — Anatomy. — The  artery  lies  behind  and 
near  the  lower  border  of  the  rib,  the  vein  above,  and  the  nerve  below  it.  From 
near  the  angle  of  the  rib  to  the  vertebral  column  it  is  separated  from  the  thoracic 
cavity  by  the  pleura  alone,  but  in  front  of  this  it  runs  between  the  two  layers  of 
intercostal  muscles. 

Operation. — An  incision  should  be  made  just  along  the  lower  border  of  the 
rib.  After  passing  through  the  outer  plane  of  intercostal  muscles  the  artery  may 
be  seen  and  secured.  Or,  failing  in  this,  take  a  long,  curved  aneurism-needle,  and 
through  a  jjuncture  near  the  lower  border  of  the  rib  jjass  it  behind  the  artery  and 
around  the  rib,  taking  care  not  to  puncture  the  pleura.  When  the  point  of  the 
needle  is  felt  at  the  upper  margin  of  the  bone,  another  puncture  is  made  to  allow 


Fig.   17S. — Liiratiori  of  tin 


iial  pu.lH 


its  escape.  The  needle  is  now  armed  with  a  strong  catgut  and  withdrawn.  A 
pellet  of  sublimate  gauze  is  laid  over  the  skin,  between  the  points  of  exit  and 
entrance,  around  which  the  ligature  is  tied.  In  exceptional  cases  it  may  be  neces- 
sary to  remove  a  portion  of  the  rib. 

Ligation   of   the   Abdominal  Aorta — Anatomy. — The   aorta   usually  bifurcates 
upon  the  body  of  the  fourth  lumbar  vertebra^  a  little  to  the  left  of  the  median . 


WOUNDS   OF  THE   BLOOD   VESSELS— LIGATION  137 

line.  This  point  is  on  a  level  with  the  highest  point  of  the  iliac  crests,  and  is  a 
little  to  the  left  of  and  below  the  umbilicus.  The  point  of  election  is  one  inch 
above  the  bifurcation. 


Fig.   179. — Ligation  of  tlie  internal  pudic  in  the  perinceum. 

Operation. — Through  the  left  rectus  muscle  one  inch  from  the  U7ica  alba  make 
an  incision,  six  inches  long,  the  center  of  which  corresponds  to  the  umbilicus. 
Divide  all  the  tissues  down  to  the  parietal  peritona?um,  and  then  arrest  all  bleeding 
before  oj^ening  this.  The  transverse  colon  and  omentum  should  be  displaced  up- 
ward, and  if  by  posture  or  otherwise  the  small  intestine  cannot  be  displaced  so  as 
readily  to  expose  the  aorta,  the  interposed  coils  should  be  brought  out  through  the 
wound  and  kept  warm  with  sterile  towels.  With  a  blunt  director  scratch  through 
the  peritoneum  and  expose  the  aorta,  around  which  a  large  animal  ligature  should 
be  passed  from  the  right  side.     (>See  aneurism  of  the  common  iliac  artery.) 

Ligation  of  the.  Common  Iliac  Artery — Anatomy. — The  common  iliac  arteries 
extend  from  the  left  side  of  the  body  of  the  fourth  lumbar  to  the  sacro-lumbar 
junction.  It  is  crossed  by  the  ureter  in  front,  near  its  bifurcation,  and  by  some 
filaments  of  the  sympathetic  nerve  higher  up.  The  left  common  iliac  vein  lies 
wholly  internal,  and  is  on  a  plane  somewhat  deeper  than  the  artery.  The  inferior 
mesenteric  vein  crosses  the  left  artery,  but  is  within  the  peritoneal  folds.  The 
right  iliac  artery  crosses  in  front  of  both  the  iliac  veins,  passing  at  a  right  angle 
to  the  left  vein  and  obliquely  over  the  right,  until  near  its  termination  the  artery 
is  in  front  of  and  external  to  the  vein  (Fig.  177). 


138 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


Operation. — Make  an  incision  one  inch  from  the  median  line  through  the  rectus 
muscle  corresponding  to  the  artery  to  be  tied,  extending  from  about  one  inch  above 
to  about  five  inches  below  the  umbilicus.  Deal  with  the  viscera  as  just  directed. 
The  posterior  wall  of  the  peritonasuni  is  scratched  through  by  means  of  two  dis- 
secting-foreeps  and  the  aneurism-needle  passed  from  within  out. 

Ligation  of  the  Internal  and  External  Iliac  Arteries — Anatomy. — The  internal 
iliac  arterjf,  less  than  two  inches  in  length,  has  the  ureter  in  front,  its  accompanying 
vein  and  the  lumbo-sacral  nerve  behind. 

Operation. — For  the  internal  iliac  and  the  upper  portion  of  the  external  pro- 
ceed as  in  the  operation  for  the  primitive  iliac. 

For  the  lower  portion  of  the  external  iliac  proceed  practically  as  for  the  radical 
cure  nf  nhlif|uo  iiiLiiiiual  hernia.     Split  the  aponeurosis  of  the  external  oblique,  from 

the  external  inguinal  open- 
ing. Make  traction  on  the 
arch  of  the  conjoined  tendon 
and  the  internal  oblique  and 
transversalis  muscles,  and  in- 
cise the  peritonaeum.  The 
modified  Trendelenburg  pos- 
ture will  displace  the  intes- 
tines. The  inferior  epigas- 
tric vessels  should  be  avoided. 
Approach  the  iliac  from  the 
outer  side,  as  the  vein  is  in- 
ternal to  it.  Unite  the  peri- 
tonaeum with  running  catgut, 
and  if  the  incision  is  of  ne- 
cessity such  that  the  abdom- 
inal wall  may  be  weakened, 
close  the  canal  as  in  the  Bas- 
sini  operation. 

The  Gluteal  Artery. — 
Make  a  five-inch  incision,  on  a 
line  extending  from  the  spine 
of  the  last  lumbar  vertebra  to 
the  trochanter  major.  The 
center  of  this  line  will  indi- 
cate the  point  at  which  the 
artery  emerges.  Separate  with 
a  dull  instrument  the  fibers 
of  the  gluteus  maximus,  dis- 
place anteriorly  the  gluteus 
medius,  and  find  the  groove 
between  the  minimus  and 
the  pyriformis.  Follow  this 
groove  upward  to  the  bony 
edge  of  the  notch,  and  the 
artery  and  veins  will  be  found 
(Fig.  178,  upper  incision). 

The  Sciatic. — Make  an  in- 
cision, five  inches  long,  on  a 
line  from  the  middle  of  the 
sacral  spines  to  the  trochan- 
ter major.  Separate  the  fibers 
of  the  gluteus  maximus  and 
find  the  lower  border  of  the  pjTiformis.  The  great  cord  of  the  sciatic  nerve  will 
now  be  seen  emerging  from  beneath  the  muscle,  and  immediately  in  front  of  this 
the  small  sciatic  nerve  and  the  sciatic  artery.  The  internal  pudic  artery  is  just 
anterior  to  this,  upon  the  spine  of  the  ischium  (Fig.  178,  middle  incision).     The 


Fig.  ISO. — Ligation  of  the  external  iliac  in  its  lower  portion, 
and  of  the  femoral  in  Hunter's  canal. 


WOUXDS   OF   THE  BLOOD   VESSELS— LIGATIOX 


139 


sciatic  artery  may  also  be  secured  opposite  the  tuher  ischii,  along  the  outer  border 
of  which  it  runs  (Fig.  178,  lower  incision). 

The  Internal  Pudic  in  the  Perinceum. — With  the  patient  supine  and  the  thigh 
abducted,  make  an  incision  in  a  line  with  the  s^nnphysis  pubis  and  tuber  ischii. 
The  artery  will  be  found  as  it  runs  along  the  inner  margin  of  the  ramus  of  the 
pubis  (Fig.  179). 

Ligation  of  the  Femoral  Artery — Anatomy. — At  Pouparfs  ligament  the  veiii 
is  on  the  same  plane  as  the  artery,  and  immediately  internal  to  it.     One  quarter 


Fig.  ISl. — Ligation  of  the  superficial  femoral  in  Scarpa's  space. 

of  an  inch  to  the  outer  side,  and  deeper  than  the  artery,  lies  the  anterior  crural 
nerve.  One  inch  and  a  half  from  the  ligament  the  profunda  femoris  arises  from 
the  outer  aspect  of  the  common  trunk,  and  from  one  to  two  inches  lower  passes 
behind  the  superficial  femoral.  Four  inches  from  Pouparfs  ligament  the  relations 
have  changed  to  such  an  extent  that  the  femoral  vein  is  deeper  and  slightly  behind 
the  artery.  The  long  saphenous  nerve  lies  upon  the  sheath  of  the  artery,  in  its 
middle  third,  and  occasionally  sends  a  branch  through  Hunter's  canal.  The  sar- 
torius  muscle  covers  the  femoral  artery  ia  all  of  its  course  except  the  first  four 
iaches,  where  it  is  superficial. 

Operation. — A  line  from  a  point  half-way  between  the  symphysis  pubis  and  the 
anterior  superior  spine  of  the  ilium  to  the  iaternal  condyle  of  the  femuj  will  run 
over  and  parallel  with  the  femoral.     It  may  be  secured  ia  any  part  of  its  course. 

In  Scarpa's  Space. — The  point  of  election  for  tv"ing  the  superficial  femoral  is 
from  four  to  five  inches  below  Pouparfs  ligament.     With  this  as  the  center,  make 


140 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


an  incision  three  inches  long  on  the  line  already  indicated.  Beneath  the  skin  and 
fascia  some  superficial  and  unimportant  vessels  may  be  divided;  the  fibers  of  the 
sartorius  will  be  seen  in  the  lower  portion  of  the  wound,  and  should  be  drawn 
downward  with  a  retractor.  The  saphenous  nerve  will  next  be  seen  on  the  outer 
side  of  the  common  sheath  of  the  vessels.  The  sheath  should  next  be  incised,  and 
the  artery  carefully  isolated  by  inserting  a  dull  director  beneath  and  around  it 
from  the  inner  side.  The  ligature  is  passed  the  same  way.  In  this  same  plane 
an  incision  may  be  made  to  expose  the  artery  lower  down,  where  it  is  completely 
hidden  by  the  sartoriiis.  This  muscle  may  he  drawn  to  the  side  most  convenient 
to  the  operator  (Figs.  181,  182). 

In  Hunter's  Canal. — Find  the  Junction  of  the  middle  and  lower  thirds  of  the 
thigh.     In  the  femoral  line,  with  this  point  as  the  center,  make  an  incision,  about 


Fig.  1S2. — Ligation  of  the  deep  and  superficial  femoral  near  the  bifurcation  of  the  common  femoral,  and 
in  the  apex  of  Scarpa's  triangle. 


four  inches  in  length,  directly  down  to  the  sheath  of  the  sartorius.  which  is  incised 
and  the  muscle  displaced  outward.  Immediately  upon  opening  the  posterior  layer 
of  the  sheath  of  the  muscle,  the  oblique  aponeurotic  fibers  which  pass  from  the 
adductor  magnus  to  the  vastus  internus — forming  the  anterior  wall  of  Hunter's 
canal — are  seen.  These  may  be  divided  on  a  director,  or  the  sheath  opened  half 
an  inch  above  this  point.  The  saphenous  nerve  is  on  the  sheathj  and  the  vein  is 
behind  and  to  the  outer  side  (Fig.  180). 

The  Common  Femoral  Above  the  Profunda. — Make  an  incision  in  the  femoral 
line,  from  three  fourths  of  an  inch  aljo\'e  Poupai't's  ligament  downward  for  three 
inches  and  a  half..  Do  not  divide  the  ligament,  but  approach  the  artery  one  half 
inch  below.     The  superficial  epigastric  vein  and  artery  may  be  wounded.     Divide 


WOUNDS   OF  THE   BLOOD   VESSELS— LIGATIOX 


141 


the  fascia  lata,  and  pass  the  ligature  from 
within  out.  (Dissection  shown  in  Figs. 
181,  182.) 

The  Profunda  Fcmoris. — Make  an  in- 
cision in  the  femoral  line,  three  inches 
and  a  half  long,  the  center  opposite  a 
point  one  inch  and  a  half  to  two  inches 
IdcIow  Poupart's  ligament.  As  above,  ap- 
proach the  common  trunk  and  search 
along  its  outer  border  for  the  origin  of 
the  profunda^  (Fig-  182).  Pass  the  liga- 
ture from  within  out,  one  inch  from  its 


Fuj  1S3. — Ligation  of  the  popliteal  artery.  Re- 
lations of  contents  in  the  left  lower  extrem- 
ity. 


origin.      Avoid    the   branches    of    the 
anterior  crural  nerve. 

In  wounds  of  the  posterior  fem- 
oral region  it  may  be  necessary  to  tie 
this  vessel  as  well  as  for  aneurism. 
Ligation  of  the  common  femoral  is 
rarely  called  for,  and  should  only  be 
done  in  extreme  cases.  In  modern 
surgical  practice,  deligation  of  the  su- 
perficial femoral  is  comparatively  free 
from  danger. 


a^ 


Fig.   184. — Ligation  of  the  posterior  tibial  abo\  c  the  iiialli'i'lu-. 
In  a  large  majority  of  subjects  I  have  found  this  branch  given  off  one  inch  and  a  half  below 

!Tn.meTit_ 


the  ligament 


142 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION 


Ligation  of  the  Popliteal — Opera- 
si  tion. — Place  the  patient  on  his  belly, 
with  the  popliteal  space  looking  up- 
A\'ard.  Make  an  incision,  four  inches 
long,  beginning  two  inches  and  a  half 
above  the  level  of  the  joint,  at  the 
outer  edge  of  the  semi-membranosus 
tendon,  and  extending  down  through 
the  middle  of  the  space.  Dividing  the 
dense,  deep  fascia,  the  areolar  tissue 
which  surrounds  the  vessels  and  nerves 
of  the  si3ace  will  be  seen,  and  at  the 
same  time,  and  superficiality,  the  pop- 
liteal nerve.  Draw  this  and  the  vein 
which  is  immediately  below  outward, 
and  the  artery  will  be  seen  deeply  situ- 
ated, and  in  the  upper  part  of  the 
space  internal  to  the  vein.  Lower 
down  the  relations  change,  the  nerve 
crossing  superficial  to  the  vein,  and 
this  overlying  the  artery   (Fig.  183). 

Ligation  of  the  Posterior  Tibial 
Artery  at  the  Middle  of  the  Leg. — 
Make  an  incision,  half  an  inch  from 
and  parallel  with  the  inner  margin  of 
the  tibia,  three  inches  and  a  half  long. 
Avoid  the  internal  saphenous  vein. 
After  passing  the  deep  fascia,  look  for 
the  lower  tibial  fibers  of  the  soleus, 
which  fiass  obliquely  from  this  border 
of  the  tibia  backward  and  slightly 
downward.  Divide  these  on  a  direc- 
tor, and  with  the  finger  separate  the 
sural  from  the  flexor  muscles.  Ee- 
tracting  the  edges  of  the  wound,  the 
artery  will  be  seen,  with  a  vein  on 
either  side  and  the  posterior  tibial 
nerve  lying  just  behind.  The  vessels 
are  held  down  by  the  common  sheath 
of  the  deep  muscles  (Fig.  184). 

Opposite     the    Ankle-joint. — Half- 
way from  the  tip  of  the  internal  mal- 
leolus to  the  anterior  edge  of  the  tendo 
Achillis  commence  an  incision,  which 
extends  directly  upward  for 
one  inch  and  a  half.     Di- 
■5,  viding  the  skin  and  fascia 

S  upon    a    director,    cut    the 

dense  internal  annular  liga- 
\  ment.     The  artery,  with  its 

-'%_  two    veins,    will    be    found 

with    the    posterior    tibial 
nerve    and    tendon    of    the 
I        flexor    longus    pollicis    be- 
~--z  '--         hind,  and  the  flexor  longus 

"-'  digitorum  and  tibialis  pos- 

-— ^  ticus  in  front.     As  the  ar- 

FiG.  185.— Ligation  of  the  anterior  tibial  in  tiie  middle  and  lower  ^ery       CUrveS       arOUnd      the 

third  of  the  leg,  and  of  the  dorsaUs  pedis  artery.  malleolus    it   will   be   found 


WOUNDS   OF   THE   BLOOD   VESSELS— LIGATION  143 

one  third  the  distance  from  the  tip  of  the  malleolus  to  the  convexity  of 
the  heel. 

The  Anterior  Tibial  at  the  Middle  of  the  Leg. — A  line  from  a  point  half-way 
between  the  anterior  tuberosity  of  the  tibia  and  the  head  of  the  fibula  to  a  like 
point  between  the  two  malleoli,  in  front  of  the  ankle,  will  indicate  the  position 
of  this  artery.  At  the  middle  of  the  leg  make  a  four-inch  incision  in  this  line, 
dividing  everything  down  to  the  dense  fascia  immediately  over  the  muscles.  Split 
this  on  a  director  and  dissect  it  up  carefully,  searching  for  the  interspace  between 
the  tibialis  anticus  internalhr  and  the  extensor  proprius  pollicis  externally.  Find- 
ing this,  discard  the  knife,  and  with  the  finger  separate  the  muscles,  and  the  artery, 
veins,  and  nerve  will  be  found  deep  down  upon  the  interosseous  membrane,  the 
nerve  being  external  and  slightly  in  front,  and  the  veins  wound  about  the  artery. 
In  order  to  relax  the  muscles  and  admit  the  light,  flex  the  tarsus  on  the  leg 
(Fig.  185). 

At  the  Loiver  Portion. — One  inch  above  the  tip  of  the  internal  malleolus  begin 
an  incision,  and  carry  it  two  inches  upward,  in  the  tibial  line  above  given.  This 
incision  is  along  the  fibular  border  of  the  extensor  pollicis,  between  which  and  the 
tendon  of  the  extensor  communis  digitorum  the  artery  will  be  found,  with  the 
nerve  on  the  fibular  side,  and  its  companion  veins  on  either  side. 

The  Dorsalis  Pedis. — One  fourth  of  an  inch  to  the  fibular  side  of  and  parallel 
■with  the  tendon  of  the  extensor  pollicis  make  an  incision,  one  inch  long,  over  the 
tarsus.  The  artery  and  veins  will  be  seen  on  a  plane  slightly  deeper  than  the 
tendon,  with  the  nerve  on  the  tibial  side  of  the  ves.sels.  This  line  is  a  continuation 
upward  of  the  first  metacarpal  interspace  (Fig.  185). 


CHAPTEE   IX 

THE    SURGICAL    DISEASES    AND    SUKGEET    OF    THE    BONES 

Ostitis. — Inflammation  in  bone  may  be  acute  or  chronic,  general  or  circum- 
scribed, traumatic  or  idiopathic.  It  may  involve  the  periosteum  (periostitis),  tlie 
compact  and  cancellous  substance  (ostitis),  or  the  medulla  (endostitis  or  osteomye- 
litis). Endostitis  and  periostitis  may  occur  independenth^,  while  ostitis  must  almost 
of  necessity  involve  the  periosteum  or  the  endosteiuu  and  medulla. 

Periostitis  maj'  be  suppurative  or  nonsuppurative.  The  so-called  "  serous " 
periostitis  is  a  mild  form  of  infection,  the  transudate  containing  only  a  few  pus 
cells.  It  does  not  deserve  to  be  considered  as  a  separate  type.  Non-suppurative 
or  fibrous  periostitis  is  a  subacute  inflammatory  process  resulting  in  more  or  less 
permanent  thickening  of- this  membrane,  with  a  varying  degree  of  new  bone  for- 
mation (osteogenesis).  It  is  a  part  of  the  late  stages  of  the  syphilitic  process, 
and  will  be  considered  with  that  disease. 

Tuberculous  periostitis  and  ostitis  are  practically  always  associated. 

Acute  periostitis  is  usually  a  local  disease  involving  a  limited  surface  of  the 
periosteum,  although  at  times  the  entire  covering  of  a  bone  may  be  affected.  It  is 
of  more  frequent  occurrence  upon  exposed  surfaces,  as  the  spine  of  the  tibia,  upon 
the  skull  and  the  phalanges.  It  is  always  accompanied  with  great  pain  and  febrile 
movement,  requiring  at  times  immediate  relief  by  incision  and  evacuation  of 
underlying  pus  or  serous  transudate.  The  incision  should  be  free,  and  for  the 
bone  immediatel}'  beneath  the  area  of  infection  the  chisel  or  gouge  should  be  freely 
used,  in  order  to  determine  the  extent  of  involvement.  Not  infrequently  it  will 
be  found,  even  where  the  disease  has  existed  only  a  few  days,  that  the  deeper 
structures,  even  the  medulla   (osteomj'elitis),  is  involved. 

The  termination  of  inflammation  in  bone  is  in  resolution  or  local  death.  In 
resolution  the  inflammatory  embryonic  tissue  undergoes  granular  metamorphosis 
and  is  absorbed,  or  it  may  be  in  part  converted  into  now  bone.  Should  the  bone 
die,  it  may  be  cast  off  as  a  sequestrum,  or  remain  imprisoned  in  a  shell  of  new- 
made  osseous  tissue,  the  involucrum. 

WTien  the  inflammatory  process  is  severe,  oi-  the  arrest  of  nutrition  sudden  and 
complete,  necrosis  or  death  in  mass  occurs;  under  other  and  milder  conditions,  the 
process  is  known  as  caries. 

In  necrosis,  which  is  aptly  compared  to  gangrene  of  the  soft  tissues,  the  cast-off 
tissue  retains  something  of  its  original  form,  while  in  caries,  which  is  molecular 
death,  the  cell  elements  disappear  by  granular  degeneration,  leaving  no  trace  of  the 
original  structure. 

Periostitis  and  ostitis  are  infectious  diseases,  due  to  the  j)resence  of  certain 
micro-organisms,  chief  among  which  is  the  streptococcus  pyogenes  aureus.  Staphy- 
lococci, pneumococci,  the  bacilli  of  typhoid,  of  tuberculosis,  and  the  colon  bacilli, 
have  also  been  observed.  All  of  these  are  pyogenic  except  the  bacillus  tuberculosis, 
which  is,  however,  very  susceptible  to  mixed  infection. 

Acute  osteomyelitis  is  one  of  the  most  serious  diseases  of  bone,  occurring 
chiefly  in  the  period  of  rapid  growth,  from  the  eighth  to  the  seventeenth  year. 
■It  is  exceedingly  rare  in  infancy,  and  not  more  than  three  per  cent  of  all  cases 
occur  after  maturity  (W.  A.  Dennis).  It  is  met  with  in  males  oftener  than  females, 
in  the  proportion  of  three  to  one.  The  tibia  is  most  frequently  involved,  and  next 
in  order  the  femur ;  after  that  the  humerus.    The  short,  spongy  bones  are  compara- 

144 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES  145 

tively  immune.  The  jjroeess  begins  by  preference  at  or  near  tlie  epiphysis  of  the 
■upper  end  of  tlie  tibia,  or  it  may  be  tlie  lower  end  of  the  femur.  Koclier  pointed 
out  the  fact  that  pyogenic  ostitis  started  on  the  central  side  of  the  epiphysis,  while 
the  focus  of  tuberculous  infection  was  located  in  or  on  the  joint  side  of  the 
epiphj'sis.^ 

Osteomyelitis  is  almost  in  all  cases  an  extremely  painful  afEection.  From  the 
fact  that  the  medulla  is  soft  and  non-resistant,  the  infective  process  spreads  rapidly ; 
and  since  the  surrounding  bone  is  non-expansile,  absorption  takes  place  rapidly 
through  the  Haversian  canals,  with  all  the  constitutional  symptoms  of  septicaemia. 
Pain  is  exaggerated  by  any  movement  of  the  extremity,  or  by  striking  the  bone 
which  is  involved.  Immediate  evacuation  of  the  purulent  contents  is  imperative. 
The  incision  should  be  free,  the  periosteum  lifted  on  either  side  and  a  trough  cut 
through  the  compact  tissue  for  the  entire  length  of  the  medulla  involved.  In 
recent  cases  (acute  pyogenic  osteomyelitis)  it  is  best  not  to  use  the  curette  or 
sharp  spoon,  relying  for  disinfection  of  the  medullary  canal  more  upon  forcible 
irrigation  with  hot  salt  solution,  followed  b}'  1-1000  mercuric-chloride  solution, 
the  excess  of  which  is  finally  washed  out  with  the  salt  water.  The  after-treatment 
consists  in  packing  the  cavity  loosely  with  sterile  gauze,  and  then  covering  in 
the  entire  area  with  gauze  and  sterile  cotton.  The  operation  is  rendered  entirely 
bloodless  by  the  use  of  the  Esmarch  bandage,  which  should  only  be  applied  above 
the  seat  of  the  disease  for  fear  of  forcing  septic  matter  into  the  circulation. 

There  is  a  rare  form  of  subacute  or  chronic  ostitis  or  osteomyelitis  in  which 
the  infectious  area  is  limited,  the  febrile  movement  slight  and  accompanied  with 
little  or  no  pain  (Brodie's  abscess). 

Upon  the  discovery  of  these  infected  foci,  the  contents  should  be  evacuated  by 
■curetting  with  Volkmann's  sharp  spoon. 

Tuberculous  inflammation  of  bone  is  a  subacute  process,  not  as  rapidly  de- 
structive as  acute  osteomyelitis,  oftentimes  going  on  without  exacerbations  of  tem- 
perature and  without  pain  sufficient  to  attract  the  attention  of  the  patient  or  sur- 
geon. The  presence  of  a  rich  granulation  tissue,  which  is  part  of  the  tubercular 
process,  produces  molecular  disintegration  of  the  substance  of  the  bone  (caries), 
at  times  causing  death  en  masse  of  more  or  less  of  the  bony  tissue  (necrosis).  When 
the  granulation  tissue  is  exuberant,  the  name  of  ostitis  interna  fungosa  has  been 
applied.  When  caseous,  it  is  called  ostitis  interna  caseosa,  and  in  rarer  instances, 
where  the  granulation  tissue  is  scant,  the  bone  may  break  do^^Ti  in  practically  a 
■dry  molecular  disintegration,  known  as  caries  sicca. 

Tuberculous  ostitis,  or  osteomyelitis,  is  not  infrequently  converted  into  an  acute 
infectious  process  by  mixed  infection,  the  pyogenic  organisms  finding  in  the  tuber- 
culous granulation  tissue  a  suitable  medium  for  their  proliferation  and  develop- 
ment. Whether  it  be  an  acute  or  chronic  myelitis,  operative  interference  is  de- 
manded. In  tubercular  disease  of  the  vertebral  column  direct  interference  is  not 
possible,  and  this  form  of  tubercular  disease  of  bone  will  be  considered  in  the 
treatment  of  Pott's  disease.  In  all  accessible  locations  the  indications  are  exposure 
■of  the  part  affected  by  incision  as  free  as  possible,  and  a  thorough  removal  by  the 
chisel  or  spoon  of  all  diseased  bone.  It  is  better  in  all  cases  to  treat  such  wounds 
by  the  open  method,  changing  the  dressing  every  two  to  four  days  as  indicated. 

Osteomalacia — Rachitis. — Osteomalacia  (mollities  ossium)  is  a  disease  of  adult 
life,  and  is  especially  apt  to  occur  in  child-bearing  women.  The  chief  pathological 
■change  is  the  disappearance  of  the  earthy  constituents  from  the  bones,  and  their 
presence  in  the  blood  and  excretions  in  abnormal  proportion.  Softening  is  often 
present  to  such  an  extent  that  marked  distortions  occiir  from  muscular  contraction 
and  superincumbent  weight.  The  medulla  of  the  bones  is  the  seat  of  congestion, 
often  resulting  in  extravasation  of  blood.  In  the  later  stages  the  bony  lamellse 
disappear  by  absorption,  the  process  commencing  from  within. 

The  treatment  consists  in  the.  prevention  of  fracture  and  deformity  by  proper 
precaution,  and  the  restoration  of  the  osseous  system  to  its  normal  condition  by 
generous  diet,  studied  hygiene,  tonics,  and  the  administration  of  the  h_^q3ophosphites 
of  lime  and  soda,  with  cod-liver  oil  and  iron. 

'  "General  Surgery,"  J.  B.  Murphy,  1907. 


146  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 

Rachitis,  or  "  richets,''  is  strictly  a  disease  of  childhood  and  youth.  Although 
it  attacks  the  entire  osseous  system,  its  disastrous  effects  are  chiefly  observed  in 
the  bones  of  the  skull  and  the  long  bones  of  the  lower  extremities.  The  bones  of  the 
skull  become  thickened  and  prominent,  the  sternum  is  advanced  and  angular 
("pigeon-breast"),  and  the  bones  of  the  lower  extremities  are  curved  antero- 
posteriorly  or  laterally.  While  the  diameter  of  a  rachitic  bone  is  usually  increased 
at  all  points,  the  enlargement  is  more  marked  near  the  extremities.  Kickets  is  a 
disease  of  malnutrition.  Its  chief  pathological  feature  is  the  formation  of  an 
embryonic  tissue,  which  in  the  normal  condition  is  converted  into  bone,  but  in  the 
rachitic  diathesis  only  partially  (if  at  all)  undergoes  ossification.  The  cells  of 
the  periosteum  are  unusually  active  in  this  proliferation,  as  are  the  cartilage  bone- 
making  cells;  yet  this  new  tissue  remains  in  great  part  embryonic,  without  the 
formation  of  the  osseous  lamellfe. 

The  treatment  of  rickets  is,  first,  to  prevent  deformity,  and,  secondly,  to  relieve 
the  dyscrasia.  Eachitic  children  should  be  kept  in  the  recumbent  posture,  -or,  if 
allowed  to  stand  or  walk,  artificial  support  should  be  given  to  the  lower  extremities 
and  spine.  The  medical  indications  are  nutritious  diet,  out-of-door  life,  and  the 
administration  of  the  hypophosphites  of  lime  and  soda,  with  cod-liver  oil  and  tonics. 
The  correction  of  the  deformities  which  may  result  from  rickets  will  be  considered 
in  the  chapter  on  Orthopsdic  Surgery. 

Acromegaly. — This  term  is  applied  to  a  condition  of  hypertrophy  of  certain 
bones  of  the  body,  as  well  as  an  increase  of  the  soft  structures.  The  hands  and 
feet  in  many  instances  become  enormously  enlarged  and  out  of  proportion  to  the 
rest  of  the  body,  while  in  others  the  bones  of  the  head  and  face,  especially  of 
the  lower  jaw,  are  aifected.  The  central  viscera  are,  as  a  rule,  not  involved.  It  is 
usually  a  symmetrical  disease,  the  corresponding  bones  of  the  two  sides  of  the 
body  being  alike  aifected.  It  gives  to  the  individual  a  peculiar  and  unnatural 
appearance. 

Actinomycosis  of  bone  is  a  rare  affection,  but  should  be  borne  in  mind,  as  it  is 
occasionally  met  with,  especially  in  the  lower  jaw,  infection  taking  place  through 
the  alveolar  process  from  a  decayed  tooth. 

Hydatid  cysts  and  cysts  due  to  hsematoma  have  also  occasionally  been  met  with 
in  the  bones. 

Syphilitic  ostitis  and  periostitis  are  given  in  the  chapter  on  Syphilis.  Periosteal 
gumma  is  met  with  most  frequently  upon  the  bones  of  the  skull  and  upon  the  tibia, 
this  painful  affection  being  more  marked  when  the  patient  retires  at  night.  The 
deeper  gumma  of  bone,  also  due  to  the  presence  of  the  lymphoid  tissue  of  the  S5rph- 
ilitic  process,  in  common  w-ith  periosteal  gumma,  does  not  suppurate  imless  mixed 
infection  occurs. 

Ostitis  deformans  (Paget's  disease)  may  occur  in  any  of  the  bones.  In  some 
cases  this  affection  resembles  osteomalacia,  in  which,  from  pressure  or  superin- 
cumbent weight,  the  bones  give  way,  producing  all  kinds  of  deformities.  It  is  a 
general  disease  and  symmetrical,  the  bones  of  the  two  sides  being  alike  involved. 
After  the  deformities  have  occurred,  a  supernatural  hardening  (sclerosis)  takes 
place,  leaving  the  bones  harder  than  normal. 

.  Exostoses,  or  new  formations  of  bone,  are  occasionally  met  with.  They  occur 
quite  frequently  after  a  fracture  near  the  insertion  of  a  group  of  muscles  (as  at 
the  trochanter),  and  are  the  cause  of  much  inconvenience  and  pain.  Upon  the 
skull  they  usually  result  from  an  injury  or  a  subacute  periostitis.  They  form  here 
dome-like  or  sessile  tumors,  while  on  the  long  bones  they  are  often  stalactite  in 
shape.  All  such  neoplasms  sliould  be  thoroughly  removed  by  the  chisel  or  Volk- 
mann  sharp  spoon  as  soon  as  discovered.  The  tendency  of  these  growths  to  undergo 
malignant  change   (sarcoma,  carcinoma)   has  long  been  recognized. 

Feactdees 

Fractures  are  partial  or  complete ;  transverse,  oblique,  or  longitudinal ;  single, 

double,  or  multiple;  simple,  comminuted,  compound,   complicated,  and  impacted. 

Partial,  when  a  bone  breaks  on  one  side   (convex  surface)   and  bends  without 


THE   SURGIC-Ai   DISEASES   AXD   SURGERY   OF   THE   BOXES  147 

breaking  on  the  op2:)osite  side  (green-sticlc  fracture,  chieily  in  the  very  young). 
Complete,  when  the  break  extends  entirely  through  the  bone.  Transverse,  v.-heii  the 
break  is  at  right  angles  to  the  axis  of  the  shaft.  In  oblique  fracture  the  direction 
of  the  line  of  cleavage  is  iisually  from  before,  upward  and  backward.  Longitudinal 
fracture  or  split  in  the  long  axis  of  a  bone  is  most  frequently  caused  by  penetrating 
wound  (gunshot)  ;  occasionally  by  a  fall  with  great  violence,  when  the  cleavage 
commences  in  an  articular  surface. 

A  single  fracture  is  one  break  in  a  bone :  double  when  two  bones  of  one  member 
(ulna  and  radius)  are  broken;  multiple  when  two  or  more  separate  breaks  occur 
in  one  or  more  bones. 

A  simple  fracture  is  a  single  break  of  one  bone,  ■without  injury  of  any  con- 
tiguous organ,  and  without  perforation  of  the  skin.  When  there  are  two  or  more 
fragments,  it  is  comminuted;  if  a  fracttire  communicates  with  the  air,  it  is 
compound;  if  it  communicates  with  the  joint,  or  involves  an  injury  of  any  im- 
portant organ  (artery,  vein,  nerve,  lung,  etc.),  it  is  a  complicated  fracture.  When 
the  fragments  interlock  with  more  or  less  complete  immobility,  it  is  impacted,  and 
when  for  any  cause  bony  union  does  not  occur,  it  is  an  ununited  fracture. 

Fractures  are  caused  by  external  violence  directly  or  indirectly  applied,  or  by 
muscular  contraction.  In  direct  violence,  the  bone  breaks  immediately  where  the 
injury  is  received.  An  example  of  indirect  violence  is  fracture  at  the  hip  from  a 
fall  on  the  feet,  or  at  the  base  of  the  skull  from  a  blow  on  the  vertex,  iluscular 
contraction  not  infrequently  fractures  the  patella;  this  bone  is  also  frequently 
broken  by  direct  violence  (a  fall  on  the  knee). 

Certain  conditions  of  the  bones  predispose  to  fracture.  Those  of  the  aged 
break  more  readily  and  repair  more  slowly  than  the  j'oung  and  middle-aged.  There 
is  often  a  fragility  of  the  bones  in  certain  forms  of  insanity ;  also  in  osteomalacia, 
and  occasionally  in  rachitis. 

3Ien  suffer  more  frequently  than  women,  on  account  of  exposure,  and  the  bones 
of  the  right  side  are  more  frequently  broken  than  the  left. 

Symptoms  and  Diagnosis. — The  loss  of  fimction,  absence  of  normal  contour, 
shortening,  abnormal  mobility,  crepitus,  and  pain  are  the  usual  symptoms.  When 
not  impacted,  a  l)roken  bone  no  longer  acts  as  a  support,  or  sustains  muscular 
contraction.  Displacement  of  the  fragments  causes  loss  of  the  normal  contour  or 
shape.  Overlapping  will  be  recognized  by  careful  manipulation,  while  comparative 
measurements  will  show  shortening.  Crepitus  or  grating  may  be  felt  when  the 
broken  ends  are  moved  upon  each  other. 

The  diagnosis  of  impacted  fracture  is  more  difficult,  since  crepitus  and  mobility 
are  not  present.  Measurement  will  reveal  shortening,  which  with  partial  loss  of 
function  and  pain  where  the  break  has  occurred  will  aid  in  the  recognition  of 
the  lesion.  A  longitudinal  fracture  or  fissure  is  difficult  of  recognition,  and  may 
escape  detection  unless  the  Eoentgen  ray  be  employed.  The  X-ray  either  with  a 
fluoroscope  (preferably  a  radiograph  carefully  taken)  is  of  inestimable  value  in 
recognizing  the  exact  nature  of  a  fracture,  and  should  be  employed  in  all  obscure 
cases. 

Prognosis. — A  guarded  prognosis  should  be  the  rule  of  practice.  "\^liile  an 
tmcomplicated  fracture  in  a  young  or  middle-aged  person,  in  good  physical  con- 
dition, if  skillfully  treated  will  unite  promptly  and  oftentimes  without  appreciable 
deformity  or  loss  of  function,  a  large  proportion  of  fractures  do  not  terminate  so 
favorably.  This  is  especially  true  when  the  lesion  is  near  a  joiat  or  when  an 
important  nerve  or  vessel  or  other  organ  is  involved  by  contiguity. 

Simple  fracture  of  the  humerus  is  not  infrequently  followed  by  paralysis, 
partial  or  complete,  to  those  muscles  which  receive  their  motor  impulse  through 
the  musculo-spiral  nerve ;  the'  splintered  bone  may  injure  the  nerve,  or  later  callus 
may  press  upon  it. 

Fractures  at  the  elbow,  imder  most  competent  management,  are  frequently  fol- 
lowed by  impairment  of  function.  The  same  may  be  said  of  fractures  at  the  hip. 
In  the  aged,  or  in  patients  with  rachitis  or  osteomalacia  or  any  constitutional 
disease,  delayed  union  or  non-imion  may  occur. 

Wlien  the  displacement  is  extreme,  and  where  the  soft  tissues  interpose,  or  when 


148  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 

the  fracture  has  occurred  in  that  part  of  a  bone  normallj'  deficient  in  nutrition 
(as  in  the  humerus  and  tibia  above  tlie  nutrient  foramina),  callus  is  often  deficient 
and  the  process  of  repair  imperfect. 

In  compound  fractures,  which  are  infrequently  complicated  by  infection,  union 
is  delayed  and  may  fail  entirely,  while  in  extreme  cases  amputation  on  account  of 
cjangrene  or  septicaemia  becomes  imperative.  This  fracture  when  communicating 
with  a  joint  is  one  of  the  most  serious  surgical  lesions. 

Treatment. — To  prevent  infection  and  to  readjust  the  broken  and  displaced  ends 
to  as  near  the  normal  as  jjossible,  and  hold  them  there  immovably  until  reunion 
occurs,  is  the  end  and  aim  of  treatment.  To  do  this  it  is  essential  to  recognize 
the  exact  conditions  at  the  point  of  fracture  by  means  of  the  X-ray,  when  neces- 
sary, or  a  careful  examination  under  the  relax-ation  of  complete  narcosis. 

While  in  some  of  the  simpler  lesions  (fracture  of  the  clavicle)  an  anEesthetic 
is  not  absolutely  necessarj^,  and  while  in  other  lesions  (as  in  Colles'  fracture)  the 
brief  narcosis  of  nitrous-oxide  gas  may  suffice,  in  fractures  of  the  long  bones, 
especially  in  muscular  subjects,  and  in  compound  or  complicated  lesions,  complete 
narcosis  is  imperative. 

While  the  mechanism  of  reduction  and  treatment  will  be  given  in  connection 
with  special  lesions,  it  may  be  said  in  general  that  in  fractures  of  the  long  bones 
a  plaster-of-Paris  dressing,  carefully  adjusted  and  watched,  yields  the  most  satis- 
factory result;  and  since  this  material  can  now  be  obtained  in  prepared  roller- 
Ijandages,  hermetically  sealed  to  prevent  the  absorption  of  moisture,  there  can  be 
no  good  reason  why  it  may  not  be  employed.  There  is  no  objection  to  its  imme- 
diate application  on  account  of  swelling,  and  no  danger  of  gangrene  when  the 
ordinary  precautions  are  taken.  In  its  application  an  ordinary  bandage-roller  is 
usually  appilied  next  to  the  skin,  while  the  moistened  plaster-roller  is  wound  rather 
loosely  aroimd  the  member  and  immediate^  molded  to  its  surfaces  by  the  hands 
of  the  operator.  It  hardens  so  rapidly  that  only  a  few  minutes  are  required  to 
secure  immobility. 

It  is  a  wise  precaution,  when  the  patient  is  at  a  distance,  as  soon  as  the  cast 
hardens  to  cut  it  in  its  entire  length,  and  divide  with  a  scissors  a  turn  or  so  of 
the  underlying  bandage  at  the  upper  and  lower  ends.  Should  swelling  occur,  .the 
nurse  or  attendant  should  be  instructed  to  divide  the  remaining  turns  of  the  roller 
next  to  the  skin,  and  to  separate  the  margins  of  the  plaster  cast  in  the  line  of 
section.  Strips  of  bandage  tied  around  the  cast  every  few  inches  of  its  length 
will  hold  the  broken  limb  practically  as  immovable  as  if  it  nad  not  been  cut.^ 

Process  of  Repair. — In  simple  fracture,  the  immediate  result  is  haemorrhage 
from  the  vessels  of  the  periosteum,  the  compact  substance  and  medulla,  as  well 


Fig.  1S6. — Periosteal  formation  of  bone  from  osteoblasts         FiG.  187. — A  bone  cell  isolated  and  highly 
a;  fe,  newly  formed  bone;  c,  old  bone.      X  300.    (After  magnified,     a.  Proper  wall  of  the  la- 

Tillmanns.)  cuna,  shown  at  a  part  where  the  corpus- 

cle, has  shrunk  away  from  it.      (After 
Joseph  and  Quain.) 

as  the  accidental  bleeding  from  the  contiguous  soft  structures.     The  eoagulum  of 
blood  and  lymph  covers  the  broken  ends,  extends  a  short  distance  into  the  medul- 

•  Plaster-rollers  should  be  submerged  in  warm  or  tepid  water  for  about  one  minute,  or  until 
the  bubbles  have  ceased  to  rise.  The  excess  of  water  is  squeezed  out  and  the  application  made 
at  once. 


THE   SURGICAL   DISE.\SES   ASD   SURGERY   OF   THE   BOXES 


149 


lary  cavity  and  Haversian  canals,  pressing  back  the  medulla  and  infiltratiag  the 
space  about  the  poiat  of  fracture.  Into  this  clot  and  throughout  the  inflamed  area 
the  emiorating  leucocytes  crowd,  and  all  the  phenomena  of  cell  proliferation  which 


.<^' 


^ 


-  -J 


Fig.  188. — Multinuclear  cells  from  bone  marrow,  highly  magnified,  a,  A  large  cell  the  nucleus  of  which 
appears  to  be  partlv  di\-ided  into  three  bj-  constriction;  6,  a  cell  the  enlarged  nucleus  of  -n-hich  shows 
an  appearance  of  being  constricted  into  a  number  of  smaller  nuclei;  c,  a  so-called  giant  cell  (myelo- 
plaxes)  with  many  nuclei;  d,  a  smaller  cell  with  three  nuclei;  e-i,  other  cells  of  the  marrow.  (After 
Sharpey  and  Quain.) 

their  presence  excites  takes  place.  The  periosteal  osteoblasts  (Fig.  186),  the  bone 
corpuscles  (Fig.  187)  which  fill  the  lacunae,  the  "giant  cells,"  of  myeJopIaxes  of 
Eobin  (very  large  masses  of  protoplasm,  containing  usually  many  nuclei,  Fig. 
188  c),  or,  if  only  one,  this  very  large, 
and  the  common  and  very  much  smaller 
mononuclear  cells  of  the  medulla  (mar- 
row cells.  Fig.  188)    (fotmd  not  only  in 


Fig.  189. — Fracture  healed  with  deformity  (callus  luxurians.)      (After  Tillmanns.) 

Fig.  190. — Longitudinalsectionthroughafractureof  the  femur  three  weeks  old.  P,  periosteum :  it ,  bone; 
M,  medulla.  Periosteal  callus  and  medullar\'  callus.  The  intermediary.-  callus  consisting  of  perios- 
teal granulation  tissue,  which  is  ossified  only  in  some  places  and  is  partly  cartilaginous.  (After 
Tillmanns.) 

the  central  medulla,  but  also  in  the  Haversian  canals,  and  possessing  the  amoeboid 
properties  of  the  leucocytes),  all  undergo  active  proliferation.  The  deeper  cells 
of  the  periosteum  are  at  first  most  active  and  throw  out  a  rich  mass  of  embryonic 


150  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BOXES 

tissue,  which  envelops  and  surrounds  the  brolven  ends  and  by  the  tenth  day  begins 
to  be  infiltrated  with  lime  salts  to  form  a  callus.  From  the  fifteenth,  to  the  twen- 
tieth day  this  (Fig.  190)  ensheathing  callus  is  complete  and  holds  the  fragments 
immovable  while  the  process  of  ossification  is  going  on.  There  forms  also  about 
the  same  time,  in  the  young,  a  weaker  callus  from  the  central  medulla  cells  (pin 
callus)  and  from  the  marrow  cells  of  the  Haversian  canals — the  interosseous  callus. 
In  older  persons,  after  about  fifty  j^ears,  it  is  held  that  no  central  or  pin  callus 
forms.  It  is  probable  that  in  all  cases  the  chief  factor  in  the  regeneration  of  bone 
is  the  bone  corpuscle  (Fig.  187).  It  is  well  known  that  the  periosteal  cells  (osteo- 
blasts, Fig.  186))  will  reproduce  bone  in  children  and  in  early  adult  life,  and  in 
inflammation  this  doubtless  assists  in  the  process,  but  the  bulk  of  their  product 
usually  disappears  by  absorption,  as  does  the  medullary  c^allus.  In  that  portion  of 
the  embryonic  tissue  which  springs  from  proliferating  bone-corpuscles _and  usually 


Fig.  191. — Lacunar  absorption  of  bone  by  osteoclasts  (O),  which  lie  in  Howship's  lacunte.      X  250. 

(After  Tillmanns.) 

is  interposed  between  the  contiguous  surfaces  of  fractured  bone,  the  cells  are  trans- 
formed into  hyaline  substance,  in  which  cartilage  cells  appear.  As  in  tlie  original 
development  of  Ijone,  this  cartilage  is  soon  infiltrated  by  true  osteoblastic  tissue, 
forming  the  osseous  lamellis.  In  addition  to  the  osteoblasts  there  appear  multi- 
nucleated cells  (myeloplaxes  of  Eobin  and  osteoclasts  of  Kolliker)  which  arrange 
themselves  in  rows  or  circles  and  cause  partial  absorption  of  the  osseous  substance, 
giving,  according  to  Sharpey,  the  festooned  appearance  to  the  Haversian  spaces 
(Fig.  191).  Through  these  canals,  thus  produced  by  absorption,  the  new-formed 
vessels  make  their  way. 

While  the  process  of  repair  in  bone,  as  just  given,  is  closely  analogous  to  the 
formation  of  bone  from  the  lilastoderm — namely,  primary  formation  of  cartilage 
and  the  replacement  of  this  by  osteogenic  tissue — this  does  not  always  occur.  In 
certain  bones  of  the  skeleton  (the  flat  bones  of  the  skull)  osteogenesis  is  not 
preceded  by  cartilage  formation.  In  inflammation  with  loss  of  substance,  when 
suppuration  has  occurred,  as  in  an  infected  compound  fracture,  embryonic  tissue 
is  directly  converted  into  bone. 

When  overlapping  occurs  or  when  soft  tissues  intervene,  the  formation  of  callus 
and  new  bone  is  interfered  with  and  the  fracture  may  remain  ununited.  In  from 
thirty  to  sixt}^  days  the  greater  part  of  the  ensheathing  callus  is  absorbed.  The 
intermediate  callus  is  formed  into  permanent  bone,  and  while  the  pin  callus  may 
occasionally  occlude  the  medullary  canal  by  permanent  osteogenesis,  it  is  usually 
absorbed. 

Special  Fractures — Craninm. — Fractures  of  the  skull  are  usually  caused  by 
direct  violence,  but  not  infrequently  a  blow  received  on  the  upper  portion  of  the 
skull  may  cause  a  fracture  at  the  base  without  breaking  the  bone  at  the  point  of 
injury.  The  base  of  the  skull  is  occasionally  fractured  by  a  fall  on  the  Inittocks. 
the  force  being  transmitted  along  the  spinal  column. 

With  these  injuries  there  may  or  may  not  he  compression  of  the  brain  or  men- 
inges. Indentation  of  the  skull  may  occur  without  depression  of  the  inner  or 
vitreous  table;  more  frequently  both  tables  are  involved. 

Diagnosis. — When  the  scalp  is  unbroken,  fracture  may  l)e  determined  by  pal- 
pation, although  a  fissure,  or  a  fracture  without  marked  displacement,  may  escape 


THE   SURGICAL   DISEASES   .\XD   SURGERY   OF   THE   BOXES  151 

detection  unless  the  X-rav  is  employed  or  an  exploratory  incision  made.  In  frac- 
tures at  the  base,  htemorrhage  or  the  escape  of  serous  fluid  from  the  ears  or  bleed- 
ing from  the  nose  is  a  symptom.  Sudden  swelling  of  the  vault  of  the  pharynx 
(hfematoma)  is  significant  when  a  basilar  fracture  is  suspected.  Interference  with 
vision  or  the  sense  of  smell  points  to  a  lesion  in  the  anterior  fossa.  The  loss  of 
consciousness  and  paralysis,  partial  or  complete,  points  to  concussion  or  compression 
of  the  brain,  or  both. 

In  general,  the  sj-mptoms  of  compression-  are  those  of  paralysis,  usually  uni- 
lateral with  symptoms  more  pronounced  than  those  which  follow  concussion.  In 
concussion  the  patient  may  be  aroused  to  partial  consciousness,  the  biTccal  walls  are 
equally  relaxed,  the  pupils  are  equal,  and  vomiting  is  of  frequent  occurrence.  In 
other  words,  both  sides  of  the  brain  are  involved.  In  compression,  stupor  is  apt 
to  be  profound  and  prolonged.  The  facial  muscles  are  drawn  to  one  side,  while 
the  buccinator  of  the  affected  side  is  puffed  out  with  the  expiratory  effort  more 
than  its  fellow.    The  pupils  are  apt  to  be  unequal,  and  vomiting  is  not  the  rule. 

In  the  treatment  of  concussion,  the  first  indication  is  rest,  in  the  recumbent 
posture  with  the  head  elevated;  with  marked  coldness  of  the  skin  and  great  pros- 
tration or  collapse,  heat  should  be  applied  locally  and  stimulants  administered  by 
h}"podermic  injection  or  enema.  ^Yhen  shock  subsides,  cold  applications  may  be 
essential. 

When  compression  exists,  operation  is  strongly  indicated.  In  most  instances 
it  is  advisaljle  to  wait  until  shock  has  disappeared  and  reaction  established. 

Occasionally,  however,  immediate  operation  is  imperative,  and,  should  the 
patient  be  wholly  unconscious,  no  ana;sthetic  need  be  administered. 

In  comminuted  fracture,  with  depression,  under  careful  aseptic  precaution  the 
fragments  should  at  once  be  lifted  to  their  normal  position.  If  infection  can  be 
prevented,  the  vitality  of  these  fragments  is  such  that  they  readily  survive,  and 
reunite  to  form  a  solid  plate  of  bone.  It  is  always,  better  to  operate  early,  since 
the  danger  of  permanent  injury  to  brain  substance  is  increased  by  delay. 

Operation. — The  scalp  within  two  or  three  inches  of  the  incision  (or  wound, 
if  such  exist)  should  be  shaved  and  thoroughly  scrubbed  with  sterilized  brush  and 
soap,  mopped  with  ether  on  clean  absorbent  cotton,  and  then  with  1-1000  sub- 
limate solution.  The  incision  may  be  longitudinal,  crucial,  or  horseshoe  shaped, 
as  required.  Hsemorrhage  from  the  scalp  may  be  temporarily  controlled  by  strong 
retraction  while  the  operation  is  in  progress,  and  permanently  by  deeply  inserted 
continuous  sutures  of  Xo.  2  chromic-acid  catgut  in  closing  the  wound. 

When  the  fissure  is  sufficiently  wide  to  admit  a  thin,  dull-pointed  instrument, 
this  may  be  employed  to  lift  the  depressed  piece,  using  the  sound  edge  as  a  fulcrum. 
With  a  narrow  fissure,  the  dura  will  need  to  be  exposed  by  a  half-inch  trephine 
or  chisel.  Preference  for  Gait's  trephine  is  based  on  the  fact  that  its  conical  shape 
makes  it  easier  to  avoid  wounding  the  dura.  Before  applying  it,  the  periosteum 
should  be  incised,  lifted,  and  held  aside  over  a  space  large  enough  to  admit  the 
trephine. 

The  bit  of  this  instrument  projected  about  one-eighth  of  an  inch  beyond  the 
level  of  the  teeth,  is  now  applied  near  the  fissure  on  the  sound  side,  so  that  about 
one  third  of  the  disc  ^vill  be  removed  from  the  depressed  bone.  After  the  first 
few  turns,  when  the  disc  has  been  well  outlined  by  the  teeth,  the  bit  should  be 
withdrawn  for  fear  of  penetrating  the  dura. 

When  the  vessels  situated  between  the  outer  and  the  inner  plate  (diploe)  are 
reached,  slight  haemorrhage  will  occur.  After  this,  pressure  upon  the  trephine 
should  be  cautiously  employed.  It  should  be  removed  at  frequent  intervals,  in 
order  to  cleanse  its  track  of  bone-dust  with  the  '"'  eye-end  "  of  a  Hagedorn  needle, 
so  that  the  first  point  of  exposure  of  the  dura  may  be  seen.  Through  this  the 
needle  or  a  stronger  instrument,  as  an  elevator,  should  be  inserted,  and  the  button 
removed. 

On  account  of  the  small  diameter  of  the  disc,  it  is  not  necessary  to  replace  it. 
Osteogenesis  takes  place  from  the  periosteum  and  dura  -nnthin  a  few  weeks,  form- 
ing permanent  bony  protection. 

In  closing  the  scalp  wound,  a  catgut  drain  should  be  left  at  each  angle. 


152  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 

Fractures  at  the  base  of  the  skull  rarely  require  operation,  although  injuries  in 
the  lower  occii^ital  region,  over  the  temporal  bones,  and  occasionally  in  the  anterior 
fossae,  will  justify  surgical  interposition.  Should  infection  supervene,  with  symp- 
toms of  meningitis  or  intra-cranial  abscess,  exploration  is  demanded.  The  same 
procedure  is  imperative  when  symptoms  of  compression  from  haemorrhage  are 
present. 

Nasal  Bones. — A  blow  upon  the  nose  may  break  one  or  both  nasal  bones,  the 
septum,  and  occasionally  the  cartilages.  This  fracture  is  almost  always  compound, 
and  depression  with  deformity  the  rule.  Haemorrhage  is  usually  severe,  chiefly 
from  the  mucous  surface,  and  may  require  compression  by  plugging.  Before  re- 
sorting to  this,  a  spray  of  adrenalin  or  the  injection  of  cold  or  very  warm  water 
should  be  tried,  unless  the  operator  has  decided  that  plugging  is  necessary  to  hold 
in  position  the  replaced  fragments.  It  is  in  general  advisable  to  employ  an  antes- 
thetic  before  reposition  can  be  satisfactorily  efEected.  A  strong,  narrow,  blunt 
instrument  should  be  passed  along  the  septum  until  it  is  in  contact  with  the  inner 
surface  of  the  depressed  fragments,  which  should  be  pressed  outward  to  their  nor- 
mal position. 

When  the  fracture  is  multiple,  and  especially  when  both  bones  of  the  septum 
are  involved,  the  following  method  is  advised :  '■ 

After  reposition,  a  large,  round  sewing  needle  is  passed  so  as  to  transfix  the 
nose,  being  made  to  enter  through  the  line  of  fracture  and  forced  through  the 
unbroken  bone  and  skin  of  the  opposite  side.  A  second  or  third  needle  may  be 
required  when  there  is  a  severe  comminution.  A  soft  silk  thread  may  be  carried  in 
figure-of-8  fashion  between  the  two  ends  of  each  needle,  which  are  shielded  with 
wax.     They  may  be  removed  aboiat  the  seventh  day. 

"When  one  bone  is  broken  and  the  depression  is  slight,  a  satisfactory  local  anses- 
thesia  may  be  obtained  by  'a  spray  of  five-per-cent  cocaine  solution  to  the  mucous 
surface,  combined  with  the  instillation  of  a  two-per-cent  solution  beneath  and  into 
the  skin. 

It  is  important  that  fractures  of  the  nasal  bones  be  reduced  within  a  few  hours 
after  the  injury  before  swelling  supervenes  to  such  an  extent  as  to  render  it  difficult 
accurately  to  replace  the  fragments.  Deformities  of  the  nose  due  to  old  and  badly 
united  fractures  of  the  nasal  bones  may  be  greatly  relieved  by  comminution  of  the 
deformed  bones  and  reshaping  them.  A  special  forceps,  which  is  inserted  under 
the  skin  and  mucosa,  is  employed. 

Malar  Bones. — Fracture  of  these  bones,  though  rare,  is  always  the  result  of 
great  violence,  which  frequently  involves  the  superior  maxilla.  Eeposition  by  means 
of  an  elevator  should  be  made  at  once.  None  of  the  fragments  should  be  removed, 
since  the  vitality  of  the  bones  of  the  face  is  so  great  that  necrosis  after  injury  is 
exceptional.  When  the  impaction  is  firm,  the  bullet-screw  elevator  may  be  em- 
ployed to  replace  the  fragments,  or  through  a  small  incision  a  narrow  instrument 
may  be  passed  beneath  the  zygomatic  arch,  in  order  to  lift  the  bone  into  place. 

In  fracture  of  the  zygomatic  process  (malar  or  temporal),  a  strong  silver 
wire  may  be  carried,  by  means  of  a  full-curve  Hagedorn  needle,  through  the 
soft  tissues  beneath  the  bone,  and  used  as  a  means  to  pull  it  back  to  its  normal 
position.^ 

A  narrow  splint,  resting  on  a  pad  of  gauze  and  held  in  place  by  the  wire  twisted 
over  it,  will  hold  the  bone  in  position  until  union  occurs.  In  ten  days  or  two 
weeks  the  splint  and  wire  may  be  removed. 

Superior  Maxilla. — A  blow  received  upon  the  upper  teeth  may  fracture  the 
alveolar  and  palatal  arch,  at  times  involving  the  antrum  maxillare. 

The  treatment  consists  in  early  reposition  of  the  fragments  to  their  normal 
position. 

When  there  is  a  wound  through  the  cheek,  this  should  be  closed  aseptically 
with  drainage  into  the  mouth,  in  order  to  prevent  an  eschar  of  the  face. 

When  the  teeth  are  displaced  and  reposition  effected,  the  soft  gutta-percha  in- 
terdental splint  may  be  required  as  in  fracture  of  the  lower  jaw. 

'  Method  of  Dr.  Lewis  D.  Mason,  of  New  York. 
^  Method  of  Prof.  Rudolph  Matas. 


THE   SURGICAL   DISEASES   AXD   SraGERY   OF   THE   BO-\ES 


153 


Lower  Jaw. — Fracture  of  the  inferior  maxilla  may  occur  in  rare  instances 
through  the  sj-mphysis,  but  much  more  frequently  the  break  is  near  the  mental 
foramen. 

Fracture  of  the  angle  or  ramus  is  infrequent,  and  is  usually  the  result  of  a 
blow  upon  the  side  of  the  jaw. 

The  coronoid  process  is  rarely  broken,  except  by  a  penetrating  body.  The 
condyle  may  be  broken  by  a  fall  or  blow  on  the  cMn,  or  by  a  powerful  fgrce  applied 
laterally  at  or  near  the  angle. 

Diagnosis. — Pain  at  the  point  of  fracture,  with  loss  of  function  and  displace- 
ment are  the  chief  s^Tuptoms  of  this  injury ;  crepitus  may  at  times  be  elicited.  Loss 
of  sensation  points  to  fracture  of  the  jaw,  with  interference  with  the  fvmction  of 
the  inferior  dental  nerre.  When  the  condyle  is  broken,  the  chief  sjTnptom  is  pain, 
in  this  region,  with  partial  or  complete  loss  of  function. 

Treatment  and  Prognosis. — Pressure  from  within  the  mouth,  aided  by  counter- 
pressure  from  without,  will  easily  effect  a  reduction  of  the  displaced  fragment. 
When,  this  is  done,  the  four-tailed  bandage  (Fig.  61)  should  be  applied.  A  piece 
of  soft  sole  leather  or  gutta-percha,  about  one  eighth  of  an  inch  in  thickness, 
shotild  be  cut  from  three  to  thr£e  and  one  half  inches  wide  and  from  six  to  seven 
inches  long,  and  split  from  each  end  in  the  long  axis  to  within  three  quarters  of 
an  inch  of  the  center.  One  strip  should  be  left  about  one  half  inch  wider  than 
the  other.  The  material  should  be  dipped  in  warm  water  for  a  few  minutes,  until 
it  becomes  thoroughly  softened.  It  is  then  laid  across  the  chin,  the  upper  and 
narrow  ends  are  turned  back  parallel  with  the  body  of  the  jaw.  while  the  lower 
strips  are  turned  upward  and  made  to  cross  outside  the  horizontal  strips.  There 
is  thus  shaped  a  close-fitting  cup  over  the  chin  and  lower  jaw,  and  over  this  the 
four-tail  bandage  is  to  be  firmly  applied.  Within  a  few  hours  this  cup  will  harden 
into  an  tmyielding  dressing. 

Before  applying  the  bandage,  interdental  splints,  made  of  gutta-percha  strips 
one  and  one  half  inch  in  length  and  alxiut  one  half  inch  in  width,  are  softened 
in  hot  water  and  placed  between  the  upper  and  lower  teeth,  bridging  over  the  line 
of  fracture.  While  the  gutta-percha  is  soft,  the  teeth  should  be  driven  into  its 
substance  by  closing  the  jaws.  These  splints  keep 
the  upper  and  lower  incisors  separated  a  distance 
sufficient  to  permit  of  semUiquid  food  being  taken 
through  a  pipette. 

The  best  apparatus  is  Hamilton's  (Fig.  192), 
which  consists  of  a  chin  and  head  strap  made  of 
strong,  soft  leather,  shaped  as  shown  in  the  illus- 
tration. The  anterior  part  of  the  chin  piece  con- 
sists of  strong,  soft  cloth  sewed  to  the  leather  strip 
which  passes  beneath  the  jaw.  By  means  of 
buckles  the  pressure  can  be  accurately  adjitsted. 
The  interdental  splints  are  added  to  this  dressing.^ 

A  patient  suffering  from  this  fracture  should 
not  be  allowed  to  talk,  and  when  in  bed  should  be 
required  to  rest  upon  the  back,  so  as  to  avoid  lat- 
eral pressure  upon  the  injured  bone. 

The  prognosis  is  usually  favorable.  ITnion  oc- 
curs in  three  to  four  weeks.  There  may,  however, 
be  a  delay  in  imion,  and  in  a  certain  proportion 
of  cases  non-union  occurs. 

In  tmtinited  fracture  of  the  lower  jaw.  the  broken  stirface  should  be  exposed 
by  incision,  thoroughly  freshened  by  scraping,  one  or  two  holes  drilled  about  one 
quarter  of  an  inch  from  the  fracttired  margins  of  each  section,  and  fixation  secured 
by  means  of  silver  ■nires.  After  tmion  has  taken  place  it  is  usually  necessary  to 
remove  the  wires. 

Larynx. — Fracture  of  the  cartilages  of  the  larynx  is  a  rare  occurrence.     The 
prognosis  is  grave   in  proportion  to  the  danger  of  asphyxia  from  inflammatory 
■  Prof.  Frank  Hastings  Hamilton. 


Fig.   192. — (.\fter  Hamilton.) 


154 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 


swelling,  or  emphj'sema,  or  from  loss  of  voice  due  to  injur}'  to  the  muscles  or 
nerves  of  this  organ.  Very  serious  shock  may  follow  extensive  comminution  of  the 
cartilages  of  the  larynx.  The  oj^erative  treatment  requires  replacement  of  frag- 
ments and  perfect  rest.     Tracheotomy  may,  in  rare  instances,  be  required. 

Hyoid  Bone. — When  the  os  hy aides  is  broken,  the  fragments  may  be  brought 
into  position  by  introducing  one  finger  in  the  month  and  pressing  with  the  other 
hand  from  without.  The  application  of  a  retentive  apparatus  is  practically  impos- 
sible, and  fibrous  union  is  the  rule. 

Clavicle. — Next  to  the  radii^s,  the  collar  bone  is  most  frequently  the  seat  of 
fracture.  The  break  occurs  in  the  large  majority  of  instances  in  the  middle  third ; 
in  children  it  is  rarely  complete.  It  may  be  caused  by  direct  violence  or  indirectly 
hj  a.  fall  upon  the  shoulder  or  the  extended  arm.  The  classical  displacement  is 
shown  in  Fig.  193.  The  sterno-mastoid  muscle  and  costo-clavicular  ligament  hold 
the  inner  fragment  practically  immovable.  The  weight  of  the  arm  and  shoulder 
drags  the  outer  fragment  downward,  while  contraction  of  the  pectoralis  major  and 
latissimus  dorsi  and  subclavius  muscles  carry  it  toward  the  middle  line  beneath  the 
inner  fragment. 

The  diagnosis  may  be  determined  by  piain  at  the  seat  of  lesion,  possilile  crepitus, 
loss  of  function  and  symmetry,  shortening  when  compared  with  the  opposite  side, 
and  recognition  of  displacement  by  palpation. 

The  prognosis  is  good  as  to  restoration  of  function,  although  in  complete  frac- 
ture, overlapping  and  a  certain  amount 
of  23ermanent  deformity  and  shortening 
are  almost  inevitable. 


Fig.   193.— (From  Gray.) 


Fig.   194. — The  first  strip. 


Treatment. — Cut  two  strips  of  strong  adhesive  plaster  (mole-skin)  three  inches 
wide  and  of  sufficient  length.  Just  above  the  elbow  of  the  injured  side,  one  strip 
with  adhesive  surface  nearest  the  body  (the  non-adhesive  surface  in  contact  with 
the  arm)  is  jjassed  around  the  arm,  and  secured  with  a  safety  pin,  so  that  it  will 
not  constrict  (Fig.  194).  The  patient's  hand  is  now  placed  over  the  middle  of  the 
sternum,  while  the  operator,  placing  his  hand  under  the  elbow  of  the  affected  side, 
lifts  the  arm  and  shoulder,  at  the  same  time  carrying  it  well  backward,  and  while 
securely  held  in  this  position,  the  plaster  is  drawn  directly  around  the  body,  first 
across  the  back,  then  in  front  and  beneath  the  elbow  of  the  injured  side,  until 
the  end  is  made  to  adhere  to  the  first  turn  in  the  middle  of  the  back  (Fig.  194). 
This  position  disengages  the  outer  fragment  from  beneath  the  inner,  and  it  is  now 
ready  to  be  lifted  to  the  level  of  the  internal  fragment.  The  second  strip,  split 
near  its  middle  for  about  three  inches  for  the  accommodation  of  the  elbow,  is  now 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES  155 

applied,  and  the  arm  and  shoulder  again  lifted  upward  until,  by  passing  the  fingers 
along  the  inner  fragment  to  the  point  of  fracture,  the  outer  fragment  is  felt  to  be 
on  the  same  level.  The  second  piece  of  adhesive  plaster  is  then  carried  in  front 
and  behind  over  the  shoulder  of  the  opposite  or  sound  side,  and  snugly  dra-\\Ti  and 
secured  so  that  the  shoulder  of  the  injured  side  remains  well  lifted  (Fig.  195).^ 


Fig.   195. — Sayre's  dressing  for  fractured  Fig.   196. — Back  view, 

clavicle.     Front  view. 

An  effective  ready  method  -  may  be  substituted  as  follows :  A  strip  of  cotton 
sheeting,  eight  inches  in  width  and  three  yards  long,  is  held  near  its  center 
across  the  palm  of  the  operator,  who,  for  the  left  clavicle,  grasps  the  elbow  of 
this  side  from  behind.  The  posterior  end  of  the  strip  is  passed  between  the  arm 
and  chest,  then  up  in  front  of  and  over  the  clavicle  of  the  injured  side,  obliquely 
across  the  back,  under  the  opposite  axilla,  thence  njDward  across  the  riglit  clavicle, 
and  to  the  back. 

The  opposite  end  is  jiassed  to  the  front  of  the  ann  at  the  elbow,  between  the 
first  strip  and  the  chest,  and  is  then  carried  around  the  back.  An  assistant  now 
carries  the  elbow  backward  and  iipward  (as  in  the  Sayre  jjosition),  and  while 
thus  held  the  ends  are  tied.  A  sling  to  support  the  forearm  is  added.  This  is 
practically  a  figure-of-8  bandage  around  the  elljow  of  the  broken  side  and  the 
shoulder  of  the  sound  side.  The  hand  is  carried  across  the  chest,  slightly  ele- 
vated, and  is  held  in  a  sling.  Safety  pins  should  be  inserted  at  the  points  of 
crossing. 

In  green-stick  fracture,  occurring  chiefly  in  children,  especially  during  the 
summer  months,  the  plaster  tends  to  produce  irritation  of  the  skin,  and  Moore's 
strip  or  Velpeau's  bandage  (Fig.  197)  is  preferable. 

The  dressing  may  be  removed  at  the  end  of  four  weeks  in  adults,  and  in  chil- 
dren with  green-stick  fractures  fourteen  days  will  suffice. 

Scapula. — Fractures  of  the  shoulder  blade  are  caused  almost  always  by  direct 
violence,  occasionally  by  muscular  contraction. 

The  acromion  process  is  usually  broken  Ijy  a  fall  on  the  shoulder  or  a  blow 
received  from  above.  It  may  be  recognized  by  crepitus,  mobility,  and  depression 
of  the  outer  end  of  the  clavicle. 

In  the  treatment  it  is  advised  to  bend  the  forearm  at  a  right  angle  to  the 
arm,  carry  a  roller  bandage  under  the  forearm  at  the  elbow  and  over  the  clavicle 
and  shoulder  of  the  injured  side,  forcing  the  head  of  the  humerus  into  the  upper 
part  of  the  shoulder-joint,  and  thus  lifting  the  acromion  into  its  normal  position. 
The  plaster-of- Paris  dressing  is  to  be  preferred.    If  union  should  fail,  and  the  func- 

■  This  is  Prof.  Louis  A.  Sayre's  method.     Fig.  195  shows  the  arm  dra-rni  too  far  to  the  front ; 
the  elbow  should  occupy  a  position  several  inches  posterior  to  that  given  in  the  drawing. 
-  Professor  Moore,  of  Rochester,  X.  Y. 


156  THE   SURGICAL   DISEASES  AND   SURGERY  OF  THE   BONES 

tion  of  the  shoiilder  be  in  any  way  impaired,  the  fragments  may  be  united  by 
wiring. 

When  the  coracoid  process  is  broken,  the  pectoralis  minor,  coraco-brachialis  and 
short  head  of  the  biceps  displace  the  fragment  downward;  the  displacement  is 
usually  very  slight. 

The  treatment  requires  the  hand  of  the  injured  side  to  be  placed  on  the  chest 
near  the  opposite  shoulder,  and  to  be  held  in  this  position  by  the  application  of 
the  Velpeau  bandage  (Fig.  197).     Fibrous  union  is  the  rule. 

Fracture  of  the  glenoid  process,  in  the  few  instances  recorded,  involves  the 
base  of  the  coracoid  as  well.  It  is  difficult  of  recognition,  and  requires  a  careful 
X-ray  photograph. 

Treatment. — Flex  the  forearm  at  right  angles  to  the  arm,  carry  it  across  the 
chest,  leaving  the  humerus  parallel  with  the  axis  of  the  body.  A  pad  is  now  placed 
in  the  axilla  and  the  humerus  forced  directly  upward  toward  the  coraco-acromial 
ligament,  and  while  held  in  this  position  a  roller-bandage  is  carried  around  and 
under  the  forearm  at  the  elbow,  and  then  over  tlie  shoulder  of  the  same  side. 
Every  other  turn  should  be  carried  horizontally  around  the  body.  By  this  means 
the  head  of  the  humerus  keeps  the  fragment  in  position.  Plaster-of-Paris  bandages 
should  be  carried  over  this  dressing  in  order  to  secure  immobility. 

Fracture  of  the  spine  or  other  portions  of  the  scapula  is  infrequent.  Velpeau's 
bandage  or  a  plaster-of-Paris  dressing  is  indicated. 

Humerus. — Fracture  of  this  bone  within  the  capsule  of  the  shoulder-joint  is 
exceedingly  rare.  Epiphyseal  sejjaration  occurs  occasionally  in  young  adults. 
Without  the  X-ray  the  diagnosis  is  very  difficult.  Shortening  is  scarcely  percep- 
tible, and  crepitus  may  not  be  present.  The  free  motion  at  the  joint  will  eliminate 
dislocation. 

The  treatment  will  be  the  same  as  that  given  for  fracture  at  the  surgical  neck. 

Surgical  Ned-. — Fracture  at  the  surgical  neck — i.  e.,  just  below  the  tuberosities 
— is  not  infrequent,  and  may  be  caused  by  a  fall  on  the  shoulder  or  a  blow  a^jplied 
directl)^  at  this  point,  or  to  force  transmitted  from  the  forearm  or  elbow. 

The  displacement  of  the  lower  fragment  is  inward  toward  the  chest  and  up- 
ward, while  the  upper  remains  poised  between  the  contractions  of  the  opposing 
muscles  attached  to  the  outer  or  inner  tuberosities. 

Diagnosis. — There  is  shortening,  motion  at  the  joint  and  fracture  line,  crepi- 
tus and  usually  deformity  due  to  the  action  of  the  pectoral  and  latissimus  dorsi 
muscles  which  carry  the  shaft  toward  the  chest.  The  head  of  the  bone  may  be 
■felt  in  its  normal  position.  Comparative  measurements  from  the  olecranon  to  the 
tip  of  tlie  acromion  process  will  reveal  shortening.  The  Eoentgen  ray  should  be 
employed  in  all  doubtful  cases. 

In  dislocation  there  is  always  stiffness;  the  muscles  of  the  shoulder  and  arm 
are  rigid,  the  humerus  is  not  parallel  with  the  chest  wall,  while  measurement  over 
the  acromion  and  around  through  the  axilla  will  show  at  least  one  inch  more 
than  on  the  normal  side.  If  the  hand  of  the  affected  side  is  laid  upon  the  opposite 
shoulder  (Dugas)  the  elbow  cannot  be  made  to  touch  the  chest,  while  in  fracture 
it  readily  falls  to  this  level. 

Treatment. — The  reduction  should  be  made  by  extension  and  counter-extension, 
under  complete  narcosis. 

Counter-extension  is  secured  by  a  towel  or  narrow  sheet  folded  under  the  axilla 
and  firmly  held,  while  the  arm  and  forearm  are  drawn  in  a  direction  parallel  with 
the  axis  of  the  body.  While  in  this  position  the  forearm  should  be  bent  at  right 
angles  to  the  arm,  and  a  plaster-of-Paris  dressing  applied  from  the  middle  of  the 
forearm  over  the  humerus,  shoulder,  and  around  the  neck  and  chest.  No  other 
dressing  gives  such  complete  immobility  and  insures  such  success.  If  plaster  is 
not  at  hand,  a  shoulder-cap  and  splint  of  leather,  gutta-percha,  or  bookbinders' 
board  may  be  made  as  follows :  A  pattern  is  first  secured  by  cutting  a  piece  of 
paper  to  fit  over  the  shoulder  and  down  the  arm  beyond  the  elbow  and  as  far  as 
the  middle  of  the  forearm.  This  cap  should  be  large  enough  to  spread  over  part 
of  the  scapular  and  pectoral  regions,  to  embrace  at  least  two  thirds  of  the  circum- 
ference of  the  arm  and  forearm,  and  to  reach  up  to  near  the  base  of  the  neck. 


THE  SURGICAL   DISEASES  AND   SURGERY  OF  THE   BONES 


157 


The  material  selected  is  cut  to  correspond  to  this  pattern,  is  then  immersed  in 
hot  water  until  it  is  soft  and  pliable,  when  it  is  lined  with  a  thin  layer  of  absorbent 
cotton  and  molded  over  the  ann  and  shoulder,  where  it  is  immediately  secured 
by  a  roller-bandage  snugly  applied.  The  inner  side  of  the  arm  is  protected  by 
cotton  batting.  The  forearm  at  right  angles  to  the  arm  should  be  included  in  the 
dressing  and  supported  by  a  sling  around  the  neck  (Fig.  198). 


Fig.  197. — Velpeau's  bandage. 
(After  Stimson.) 


Fig.  198. — Apparatus  for  fracture  of  the  humerus  at 
any  point  above  the  condyles.  (After  Hamilton.) 
The  shoulder-cap  should  extend  farther  on  the 
chest  and  neck,  as  -well  as  the  scapular  region, 
than  shown  in  the  drawing. 


Fracture  at  or  near  the  surgical 
Tieek  is  occasionally  complicated  with 
dislocation.  It  may  be  recognized  by  a  marked  depression  beneath  the  acromion 
process,  indicating  the  absence  of  the  head  of  the  humerus,  which  may  be  felt  in  the 
axilla  or  beneath  the  clavicle.  Preternatural  mobility  at  the  line  of  fracture  and 
crepitus  will  determine  the  dual  character  of  the  injury.  The  crucial  test  of  the 
Eoentgen  ra}^  will  assure  a  correct  diagnosis. 

Treatment. — An  incision  should  be  made  directly  over  the  dislocated  fragment, 
which  is  exposed  by  dry  separation  of  tlie  muscles,  not  necessarily  exposing  the 
line  of  fracture.  Near  the  level  of  the  tuberosities  a  good-sized  hole  is  drilled  at 
a  right  angle  to  the  general  direction  of  the  shaft,  deeply  into  its  substance;  into 
this  hole  a  stout  metal  retractor  shaped  like  the  letter  "  L,"  with  a  handle  at  the 
long  end  large  enough  for  the  firm  grasp  of  the  hand,  is  inserted.  By  careful 
manipulation  of  this  instrument,  with  traction  in  the  direction  of  the  rent  in  the 
capsule  aided  by  pressure  upon  the  head  of  the  bone,  the  dislocation  is  readily 
reduced  and  the  wound  closed.  The  fracture  is  then  treated  after  the  method  Just 
described.^ 

The  operation  in  these  cases  should  be  performed  at  the  earliest  possible  mo- 
ment, as  every  day  of  delay  adds  to  the  difficulties  of  reduction. 

Shaft. — Fractures  of  the  shaft  of  the  humerus,  although  chiefly  caused  by  direct 
violence,  are  not  infrequently  the  result  of  force  transmitted  from  the  elbow  or 
hand  and  forearm,  and  may  in  rare  instances  be  caused  by  muscular  contraction 
alone.  The  displacement  will  in  great  part  be  determined  by  the  direction  of 
the  line  of  fracture.  If  broken  above  the  deltoid  insertion  the  lower  fragment  is 
drawn  upward,  while  the  upper  is  carried  toward  the  chest  by  the  latissinius  dorsi 
and  pectoralis  muscles.  If  the  break  is  below  the  deltoid  tubercle,  the  lower  frag- 
ment is  apt  to  be  drawn  behind  the  upper  portion  (Fig.  199). 
'  Method  of  Prof.  Charles  McBurney. 


158 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 


Injury  to  one  or  more  of  the  nerves  which  are  in  intimate  relation  to  the  hu- 
merus not  infreqiiently  occurs.  This  is  especially  true  of  the  musculo-spiral  nerve, 
which  for  a  considerable  distance  rests  upon  the  periosteum.  Partial  or  complete 
paralysis  of  the  extensor  muscles  of  the  forearm  may  ensue,  not  only  from  direct 
injurj'  at  the  time  of  the  accident,  but  from  compression  of  the  nerve  1}y  callus. 
The  possibility  of  this  complication  should, be  imparted  to  the  patient. 

If  at  the  time  of  the  accident  there  are  evidences  of  injury  to  the  nerve,  it  is 
advised  to  treat  the  fracture  in  the  ordinary  method  and  await  developments. 
If,  after  five  or  six  weeks,  when  union  has  been  obtained,  paralysis  persists,  resection 
and  suture  of  the  nerve  ends  should  be  considered.  Exploration  will  determine  the 
necessity  for  resection.  When  due  to  pressure  from  callus  or  new-bone  formation 
at  the  line  of  fracture,  this  should  be  chiseled  away,  leaving  the  nerve  free. 

The  treatment  of  all  of  these  fraetui'es  is  practically  the  same.  Forced  exten- 
sion and  counter-extension  under  the  complete  relaxation  of  an  anoesthetic  is  essen- 
tial. While  this  is  being  done,  the  operator  should  by  careful  manipulation  satisfy 
himself  that  the  fragments  are  in  ai3iJOsition,  and  while  so  held  the  whole  meml^er, 
including  at  least  half  of  the  forearm,  the  humerus,  shoulder,  and  the  chest  should 
he  enveloped  in  plaster-of-Paris  bandages.  The  method  of  application  is  shown  in 
Fig.  46. 

Fractures  of  the  humerus  at  the  elbow  may  be  subdivided  into  (1)  tliose  of 
the  external  epieondyle,  (3)  those  of  the  internal  epicondyle,  (3)  transverse 
above  the  capsular  attaclunent,  (4)  transverse  within  the  capsular  attachment, 
(5)  those  of  the  external  condyle,  and  (6)  those  of  the  internal  cond.yle. 

The  external  and  internal  epicondyles  are  always  broken  by  direct  violence,  the 
force  not  being  great  enough  to  carry  tlie  line  of  fracture  into  the  joint.  These 
minor  lesions  may  be  recognized  by  the  X-ray,  and 
occasionally  by  a  slight  crepitus,  with  perceptible  mo- 
bility of  the  fragment.  The  movements  of  the  joint 
are  not  affected.  The  prognosis  is  favorable,  since 
the  capsule  is  not  involved,  and  there  is  rarel}'  any 
interference  with  the  function  of  the  joint.  The 
treatment  requires  a  light  plaster-of-Paris  dressing 
from  near  the  wrist  to  the  axilla,  with  the  arm  at 
a  right  angle  to  the  forearm,  the  forearm  being  in 
full  pronation  for  the  internal  and  in  full  supina- 
tion for  the  external  epieondyle.  In  this  jjosition 
the  muscles  in  relation  to  either  condyle  are  most 
relaxed.  The  splint  should  be  removed  at  the  end 
of  each  week,  and  passive  motion  made.  All  dress- 
ings should  be  discontinued  after  the  third  week. 

In  transverse  fracture  above  the  capsular  at- 
tachment there  is  usually  an  obliquity  from  be- 
fore upward  and  backward,  the  lower  fragment 
being  displaced  upward  and  behind  the  longer 
portion  of  the  shaft  (Figs.  199-203).  As  a  rule, 
the  nearer  the  line  of  fracture  approaches  the 
capsular  attachment,  the  obliquity  is  less  marked 
and  the  displacement  not  so  great.  The  diagnosis  of  this,  as  well  as  of  all  frac- 
tures which  may  possibly  complicate  the  elbow-joint,  should  be  carefully  made 
by  the  use  of  the  Roentgen  ray.  If  this  cannot  be  utilized,  the  patient  should  be 
completely  relaxed  by  full  ether  narcosis  and  the  character  of  the  injury  carefully 
studied  by  palpation.  If  swelling  has  occurred  and  sepsis  is  not  present,  the  transu- 
date may  be  forced  into  the  circulation  by  the  application  of  the  Esmarch  bandage, 
and  the  limb  reduced  to  about  its  normal  size. 

Not  infrequently  a  transverse  fracture  of  the  lower  end  of  the  humerus  above 
as  well  as  tvithin  the  capsule  involves  the  articulation  by  a  split  from  the  fracture 
line  into  the  joint  surface  (Y  fracture)  (Fig.  300).  It  is  exceedingly  important 
to  make  an  accurate  diagnosis,  since  the  treatment  must  be  determined  by  the 
conditions  present.     If-  there  has  been  a  split  into  the  joint,  treatment  in  the  posi- 


FiG.  199. — Showing  mechanism  of 
displacement  in  fracture  above 
the  condyles.     (After  Gray.) 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 


159 


tion  of  full  extension  is  essential.  If,  however,  the  operator  is  convinced  that  he 
has  to  deal  with  a  transverse  fracture  above  the  capsule,  in  no  way  communicating 
with  it,  the  position  of  flexion  of  the  forearm  at  a  right  angle  to  the  humerus 
may  be  assumed.     All  of  these  injuries  should  be   treated  by  a  plaster-of-Paris 

dressing,  snugly  applied,  and  carrying 
the  gypsum  not  only  over  the  shoulder 
of  the  broken  side  but  also  that  of  the 
opposite  side,  as  given  on  a  following 
page  (0.  H.  Allis). 


Fig.    200. — Double  condyloid  or  T-fracture  of 
the  humerus.     (Helferich.) 


Fig.  201. — Fracture  of  eminentia  capitata  and  ex- 
ternal condyle  by  force  transmitted  along  tlie 
radius  from  a  fall  on  the  hand.      (Helferich.) 


Fractures  of  the  crternal  condyle  occur  from  direct  violence  by  a  fall  or  blow 
upon  tlie  elbow,  or  by  force  transmitted  Ijy  the  radius  from  the  hand  in  falling 
forward,  the  forearm  usually  being  Ijent  at  a  right  angle  to  the  shaft  of  the 
himierus.     The  eminentia  capitata  and  the  external  condyle  are  usually  displaced 


Fig.  202. — Charles  Isaacson,  aged  twelve.    Double       Fig.  203. — ^The  same;  front  \-io^v  slmwingfracture 
fracture  with  backward  displacement.  line  entirely  across  the  liunienis  above  the  ar- 

ticular surface  and  a  second  line  of  cleavage 
from  the  external  condyle  to  the  trochlea. 
Treated  in  full  extension. 


backward.  The  line  of  fracture  begins,  as  a  rule,  near  the  center  of  the  inter- 
eondyloid  notch,  and  runs  obliquelj'  upward  and  outward,  crossing  the  external 
condyloid  ridge  at  a  varying  distance  from  the  capsular  attachment. 

Fracture  of  the  internal  condyle  is  more  apt  to  be  caused  by  a  fall  upon  the 
elbow,  although  it  may  result  from  force  transmitted  along  the  ulna  from  the 
hand.     The  symptoms  and  method  of  diagnosis  of  these  fractures  are  considered. 


160 


THE   SURGICAL   DISEASES   AND   SURGERY   OF  THE   BONES 


with  transverse  fractures  occurring  within  the  capsule  and  communicating  with 
the  Joint. 

Should  the  Eoentgen  ray  be  not  available  and  the  parts  not'  swollen,  with  the 
patient  in  ether  narcosis,  the  relation  of  the  fragments  to  the  expanding  condy- 
loid ridges  will  by  careful  manipulation  and  comi^arison  with  the  uninjured  member 
be  readily  ap23reciated.  If  swelling  has  occurred  and  there  are  no  symptoms  of 
local  infection,  the  application  of  the  Esmareh  bandage  (A.  G.  Gerster)  will  re- 
move the  transudation  and  reduce  the  arm  to  near  its  normal  size. 

In  certain  of  these  elbow  fractures  occurring  as  the  result  of  great  violence, 
and  especially  in  children,  v/here  the  epiphyseal  lines  are  yielding  and  the  several 
centers  of  ossification  are  still  present,  the  displacement  of  one  (or  more)  of  the 
condyloid  fragments  is  often  extreme,  and  reduction  with  partial  restoration  of 
function  may  only  be  hojjed  for  after  an  open  operation  with  or  without  pinning 
or  wiring.^ 

The  classical  picture  of  transverse  fracture  within  the  capsule  with  a  break 
through  the  articular  surface  is  given  in  Pigs.  202  and  203,  taken  at  the  time  of 


Fig.  204. — The  same,  six  months 
later,  showing  free  voluntary 
flexion.  The  coronoid  process 
not  fully  drawn  into  the  fossa. 


Fig.  205, — Tlic  same  showing  full  A-oluntary  extension.     The  rela- 
tions of  tlie  forearm  to  the  arm  are  normal. 


the  injury.  There  is  shown  in  the  side  view  (Fig. 
202)  the  tendency  to  upward  and  backward  displace- 
ment of  the  lower  fragment,  a  displacement  which 
is  not  easy  to  entirely  overcome,  and  which  requires 
strong  and  direct  pressure  forward,  with  counter- 
pressure  on  the  shaft,  to  hold  in  reduction  as  the 
plas'ter-of-Paris  is  setting.  Fig.  203  shows  the  trans- 
verse break  through  the  olecranon  and  coronoid  fossae, 
and ;  a  separate  fracture  through  the  external  condyle 
into;  the  articular  plane  at  the  trochlea. 

Treatmerit. — The  diagnosis  being  clear  with  the 
line  of  fracture  passing  through  the  fosste,  the  fol- 
lowing method  of  treatment  was  carried  out :  Under  ether  narcosis  strong  extension 
was  made  from  the  wrist  with  counter-extension  by  means  of  a  folded  towel  passed 
beneath  the  arm  at  the  axilla. 

With  the  limb  in  full  extension  and  nearly  parallel  with  the  side  of  the  body, 
the  fragments  were  brought  into  alignment  with  the  condj^loid  ridge  of  either  .side. 
At  the  same  time  the  lower  fragments  were  pushed  forward  while  the  shaft  of 
the  humerus  was  forced  in  the  opposite  direction.  While  held  in  this  position  a 
plaster-of-Paris  dressing  was  rapidly  applied  from  the  wrist  over  the  entire  arm. 
and  shoulder,  around  the  chest  beneath  the  axilla  of  the  opposite  side,  and  finally 
a  few  turns  of  the  roller  were  carried  over  the  clavicle  of  the  sound  side.-  As 
the  plaster  was  setting  the  tendency  of  the  upper  fragment  to  override  the  lower 
was  resisted  by  firm  pressure  and  counter-pressure. 

The  weight  of  the  plaster  cast  thus  applied  falls  upon  the  clavicular  regions 
and  relieves  the  broken  arm  of  pressure.     On  the  eighth  day  the  cast  was  split, 

1  Dr.  Carleton  P.  Flint,  New  York  Academy  of  Medicine,  1906.  Among  these  interesting 
cases  in  one  the  X-ray  had  revealed  the  complete  somersault  of  the  fragments,  the  articular  surface 
looking  upward. 

'  The  superiority  of  this  dressing  and  method  has  long  been  maintained  by  Dr.  O.  H.  AUis. 


THE   SURGICAL   DISEASES  AA"D   SURGERY   OF   THE   BONES  161 

nitrous-oxide  gas  administered,  and  while  the  fragments  were  firmly  grasped  by 
one  hand  and  held  immovable  the  forearm  was  flexed  to  about  eighty  degrees,  car- 
ried back  to  full  extension,  and  the  same  dressing  readjusted  and  snugly  held  by 
adhesive  strips.  Seven  days  later  this  was  repeated,  increasing  the  flexion  to  ninety 
degrees  and  a  new  dressing  applied.  At  the  end  of  another  week  (the  twenty-second 
day  after  the  first  application)  the  splint  was  removed,  flexion  and  extension  made 
several  times,  and  the  arm  left  perfectly  free.  There  was  at  this  time  well-marked 
resistance  to  flexion  beyond  a  right  angle,  but  force  was  not  employed  to  over- 
come this  for  fear  of  breaking  through  the  line  of  union.  Twice  a  week  regu- 
larly after  this  gas  was  administered,  the  forearm  fully  extended,  and  gradually 
increasing  flexion  made  until  by  voluntarj'  muscular  action  the  finger-tips  could 
be  made  to  come  within  an  inch  of  the  shoulder. 

Review. — Fractures  of  the  humerus  wholly  or  partly  withia  the  capsule  at  the 
elbow  offer  greater  obstacles  to  a  restoration  of  function  than  any  other  fracture. 
During  and  after  the  process  of  repair  in  most  cases  full  extension  is  more  difficult 
to  secure  than  extreme  flexion.  As  the  line  of  cleavage  almost  always  involves 
the  fossEe,  and  as  the  olecranon  is  larger,  deeper,  and  therefore  more  important, 
the  olecranon  process  should  always  occupy  this  fossa  to  the  exclusion  of  callus, 
new  bone,  or  new  connective  tissue.  Treatment  in  full  extension  better  meets  this 
requirement  than  partial  or  extreme  flexion.  Displacement  of  one  or  the  other 
condyle  with  ultimate  cubitus  varus  or  valgus  is  less  apt  to  follow  the  method  of 
full  extension.  In  all  uncomplicated  cases  passive  motion  should  be  begun  at  the 
end  of  the  first  week  and  repeated  at  the  end  of  the  second  and  third  weeks  when 
the  splint  is  discontinued. 

Without  regard  to  treatment  in  extreme  flexion  as  advocated  by  some,  or  in 
full  extension  as  advised  here,  rather  than  immobilize  the  joint  for  three  weeks 
it  were  better  to  apply  no  splint.  In  achieving  a  result  as  nearl}^  perfect  as  pos- 
sible mtroiis-oxide  gas  is  invahidble.  Even  a  timid  child,  if  carefully  managed, 
will  soon  lose  any  sense  of  dread  of  this  agent.  The  complete  relaxation  of  ether 
narcosis  (chloroform  has  great  danger  for  children)  is  essential  to  a  first  dress- 
ing. Young  and  old  will  run  from  the  frequently  repeated  administration  of  ether 
or  chloroform,  preferring  the  alternative  of  impaired  function.  The  double 
strength  of  the  flexor  muscles  as  compared  with  the  extensors  makes  a  temporary 
impairment  of  flexion  easier  to  overcome  than  an  impediment  to  extension. 


Tig.  206. — Case  ot  Talcott  Clutteiiaen.  Uuee  years  of  age,  taken  uiie  year  after  compound  extra  and 
intracapsular  fracture  of  the  humerus  at  the  elbow.  Treated  in  fidl  extension.  Power  of  extension 
and  function  perfect. 

The  rare  forms  of  transverse  fracture  of  the  humerus  which  communicate  with 
the  capsule  but  do  not  involve  the  articular  surface  should  also  be  treated  by  this 
method  of  full  extension.  Figs.  206  and  207  show  the  complete  restoration  of 
function  in  spite  of  a  rich  new-bone  formation  which  followed  a  compound  fracture 
on  this  plane. 

Forearm — Ulna. — Fracture  of  the  olecranon  process  is  usually  caused  by  a 
fall  on  the  elbow  or  a  direct  blow;  occasionally  by  contraction  of  the  triceps  mus- 
cle. The  line  of  fracture  is  usually  found  at  or  near  the  epiphyseal  junction,  and 
the  displacement  is  upward  (Fig.'  208).  The  abnormal  lateral  mobility  of  the 
upper  fragment  and  the  depression  between  it  and  the  shaft  will  render  the  diag- 
nosis easy. 


162 


THE   SURGICAL   DISEASES   AND   SURGERY   OF  THE   BONES 


Treatment. — The  following  teclmic  of  J.  B.  Murphy  strongly  commends  itself 
to  the  author.  An  incision  is  made  on  the  lateral  aspect  of  the  ulna,  long  enough 
to  expose  the  bone^  three  fourths  of  an  inch  anterior  to  the  line  of  fracture,  and 


Fig.   207. — The  same,  showing  no  impediment  to  flexion.      Function  perfect.     Tlie  extreme  range  of 
flexion  is  not  fully  shown  in  the  skiagraph. 

on  exactly  the  opposite  side  a  second  incision  is  made,  the  bone  exposed,  and  a 
hole  drilled  through  for  the  passage  of  a  strong  silver  wire.  A  long  straight  needle 
threaded  with  linen  for  carrying  the  wire  is  passed  through  this  hole,  reintroduced 
beneath  the  skin  and  other  tissues  close  to  the  bone,  and  carried  toward  the  tip 
of  the  olecranon  process,  where  it  is  drawn  out,  reinserted, 
and  carried  across  through  the  tendon  of  the  triceps  just 
where  it  takes  hold  of  the  process.  It  is  then  reintroduced 
lieneath  the  skin  and  brought  out  at  the  lower  wound,  where 
the  ends  arc  twisted,  thus  drawing  and  holding  the  fragments 
firmly  together.  The  forearm  should  be  maintained  in  full 
extension  for  three  weeks,  removing  tlie  splint  once  a  week 
for  well-guarded,  passive  motion  at  the  elbow.  Should  this 
procedure  be  declined,  the  fracture 
sliould  be  treated  after  the  method  of 
Hamilton. 


Fig.  208. — Displacement  of  the  upper  fragment 
in  fracture  of  the  olecranon.      (After  Gray.) 


(After  Hamilton.) 


plint. 


A  board  splint,  two  or  three  inches  wide  and  long  enough  to  extend  from  the 
wrist  to  the  axilla  is  notched  as  shown  in  Fig.  209.  It  should  be  padded  with 
cotton  batting,  made  twice  as  thick  at  the  bend  of  the  elbow  as  elsewhere.  Lay 
the  splint  on  the  anterior  surface  of  tlie  arm  and  forearm,  and  secure  it  near  the 
ends  by  several  turns  of  the  roller.  Then  with  a  flannel  bandage  (on  account  of 
its  elasticity),  commencing  below,  cover  the  forearm  and  splint  by  circular  turns 
until  the  notch  is  reached,  at  which  moment  the  roller  is  carried  just  above  the 
rtpper  fragment,  around  the  posterior  aspect  of  the  arm,  and  down  again,  to  be 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 


163 


secured  in  the  notch  on  the  oi^posite  side  of  the  splint.  Tliis  oblique  turn  is  repeated 
until  the  fragments  are  in  apposition,  when  the  whole  is  secured  by  as  man]-^ 
circular  turns  as  are  needed  (Fig.  210).  Strips  of  adhesive  plaster  may  be  em- 
ployed with  equal  advantage  in  making  downward  traction  upon  the  upper  frag- 


FiG.  210. — Hamilton's  dressing  for  fracture  of  the 
olecranon.      (After  Hamilton.) 


mcnt.     A  snug  figure-of-8  bandage  over  the  whole,  including  the  slioulder,  will 
aid  in  holding  the  triceps  muscle  perfectly  quiet. 

Passive  motion  should  not  be  made  until  the  end  of  the  third  weelc,  and  then 
very  sliglitly,  gradually  increasing  the  degree  of  fle.xion  until  firm  union  is  assured 
(sixth  to  eighth  week).  In  commencing  motion  the  short  fragment  should  be 
firmly  held  in  place.     Osseous  union  by  this  method  is  exceptional. 

Fracture  of  the  coronoid  process  is  exceedingly  rare,  and  a  diagnosis,  unless 
revealed  by  the  X-ray,  difficult;  it  should  be  treated  hj  fixation,  with  the  forearm 
^\■el\  flexed  upon  the  arm. 

Fracture  of  the  shaft  of  the  ulna  alone  is  caused  almost  always  by  direct  vio- 
lence. In  complete  fracture  the  diagnosis  is  not  difficrdt.  If  compression  be 
made  by  grasping  both  bones  of  the  forearm  at  a  point  remote  from  the  fracture, 
pain  or  abnormal  mobility  or  crepitus  will  be  caused  at  that  point.  Inspection  with 
the  fluoroscope  is  advisable.  The  displacement  of  the  upper  fragment  is  usually 
slight,  while  the  lower  is  drawn  toward  the  radius  Ijy  the  pronator  quadratus. 
The  obliquity  of  the  line  of  fracture  and  the  direction  of  the  force  which  pro- 
duced the  lesion  will  almost  always  determine  the  displacement. 

The  treatment  is  the  same  as  for  fracture  of  the  shaft  of  the  radius  alone  or 
of  both  bones;  the  prognosis  is,  however,  more  favorable,  since  in  fractures  of  a 
single  bone  of  the  forearm  its  fellow  acts  as  a  retaining  splint. 

Radius. — Fracture  of  this  bone,  above  the  bicipital  tuberosity  is  exceedingly 
rare,  and  is  difficult  of  recognition,  except  by  the  Eoentgen  ray.  It  is  caused  by 
direct  violence.  Displacement  of  the  upper  fragment  is  slight,  unless  the  fracture 
is  complicated  with  a  dislocation  at  the  radio-humeral  Joint.  The  action  of  the 
biceps  will  tend  to  draw  the  lower  fragment  forward.  The  best  position  for  immo- 
bilization is  to  flex  the  forearm  on  the  arm,  with  the  palm  turned  slightly  upward. 
A  plaster-of-Paris  dressing  should  he 
applied  to  hold  the  member  in  this 
position. 

Fracture  of  the  radius  lietween  the 
Ijicipital  tuberosity  and  the  insertion  of 
the  pronator  radii  teres  usually  results 
from  a  direct  blow,  although  it  may  be 
caused  by  a  fall  on  the  hand,  or  in  very 
rare  instances  by  muscular  action.  While 
the  obliquity  of  the  line  of  fracture  will 
in  great  part  determine  the  displacement, 
the  tendency  is  for  the  lower  fragment  to 
be  carried  toward  the  ulna  by  the  action 
of  the  pronator  quadratus,  while  the  upper  fragment  is  drawn  upward  and  slightly 
rotated  outward  by  the  Ijiceps.  When  the  Ijone  is  broken  below  this  point,  the 
lower  fragment  is  also  carried  toward  tlie  ulna,  while  the  upper  is  lifted  by  the 
biceps  muscle  (Fig.  211). 


Fig.  211. — Dis^^lacement  of  the  fragments  in  frac- 
ture of  the  radius  in  its  lower  third.  (After 
Gray.) 


164  THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 

Treatment. — When  both  bones  of  the  forearm  are  broken,  the  loss  of  function 
is  so  complete,  together  with  the  deformity,  which  is  always  present,  that  the 
diagnosis  is  readily  made. 

The  treatment  of  a  fracture  of  the  shaft  of  the  radins  between  the  tuberosity 
of  the  biceps  and  the  insertion  of  the  pronator  quadratus,  or  of  the  shaft  of  the 
ulna,  within  the  same  limit,  or  of  both  bones,  is  the  same. 

The  forearm  is  flexed  at  about  a  right  angle  to  the  arm,  and  under  the  com- 
plete relaxation  of  an  anaesthetic,  extension  from  the  hand,  with  counter-extension 
from  the  arm  at  the  elbow,  is  made  with  such  force  that  any  overlapping  of  the 
fragments  is  overcome.  The  forearm  should  then  be  brought  in  a  f)osition  half-way 
between  supination  and  jDronation,  the  thumb  pointing  directly  upward,  and  while 
firmly  held  in  this  position  two  board  splints  long  enough  to  extend  from  the  end 
of  the  metacarpus  to  the  elbow,  and  each  wider  tlmn  the  forearm  in  its  ividest 
portion,  properlj'  piadded  with  cotton  batting,  are  so  firmly  applied  over  the  flexors 
and  extensors  that  they  will  compress  the  muscles  of  the  forearm  into  the  inter- 
osseous sjjace  and  thus  prevent  any  possible  union  of  one  bone  to  the  other.  While 
everj'thing  is  fii-mly  held,  the  splints  are  secured  by  adhesive  strips,  snugly  applied, 
and  over  this  is  a  firmly  applied  roller-bandage.  After  three  or  io^^x  days  this  dress- 
ing usually  liecomes  somewhat  loose  on  account  of  muscular  atrophj^  and  requires 
to  be  tightened  by  applying  another  roller  over  the  first  without  removal  of  the 
splints.  These  should  be  allowed  to  remain  in  jjlace  for  three  weeks  in  children, 
four  or  five  weeks  in  middle-aged  adults,  and  five  weeks  or  longer  in  elderly 
persons. 

Fracture  of  the  Carpal  End  of  the  Radius  {Colics'  Fracture). — In  falling 
upon  the  hand,  as  the  metacarpus  and  carpus  are  forced  backward  a  great  strata 
is  thrown  upon  the  anterior  radio-carpal  ligament.  AYhen  fracture  occurs  the  bone 
begins  to  yield  on  its  anterior  aspect  close  to  and  parallel  with  the  attachment 
of  the  ligament,  the  line  of  fracture  traveling  upward  and  backward,  with  usually 
very  slight  obliquity.  In  the  majority  of  instances  the  anterior  fragment  is  forced 
upward,  and  either  overrides  the  upper  or  is  oftener  impacted  into  it  without  over- 
riding (Fig.  213).  This  displacement  causes  the  peculiar  bowed  or  silver-fork 
deformity  to  the  wrist.  With  this  upward  displacement  of  the  lower  fragment, 
a  strong  fibrous  band  spread  over  the  dorsum  of  the  radius  at  its  carpal  extremity, 
and  which  serves  to  hold  the  extensor  tendons  in  place,  is  lifted  frequently  for 
half  an  inch  or  more  (Fig.  212).  It  is  this  fibrous  band,  together  with  the 
jjartial  impaction  of  the  fragments,  Avhich  makes  reduction  by  direct  extension 
and  counter-extension  practically  imp)Ossible.  With  this  posterior,  there  is  at  times 
a  lateral  displacement,  the  lower  fragment  being  carried  outward  beyond  the  nor- 
mal level  of  the  radius;  in  very  rare  instances  the  line  of  fracture  communicates 
with  the  articular  surface,  in  other  instances  one  or  more  bones  of  the  carpus 


Fig.  212. — Colles'  fracture,  showing  the  fibrotis  band  which  prevents  reposition. 

are  involved  in  the  fracture.  The  ulna  is  also  sometimes  broken,  and  the  tendon 
of  the  extensor  carpi  ulnaris  is  displaced  from  its  groove  near  the  st_yloid  process 
of  this  bone.  A  fracture  at  the  wrist  exactly  the  reverse  of  Colles'  may  take  place 
when  the  force  is  applied  to  the  dorsum  of  the  hand  (John  B.  Koberts). 

Diagnosis. — Nothing  is  so  satisfactory  as  an  X-ray  picture  of  the  region  in- 
volved in  determining  the  exact  character  of  the  fracture.  Complications  such 
as  fracture  of  the  carpal  bones,  the  end  of  the  ulna,  a  lateral  displacement,  or  a 
comminution  of  the  lower  fragment,  can  only  be  accurately  determined  by  this 


THE   SURGICAL   DISEASES   .AN'D   SURGERY   OF   THE   BOXES  165 

method.  The  upward  displacement  and  sharp  sense  of  pain  which  is  elicited  by 
pressing  with  the  thumb  nail,  usually  about  one  haK  inch  above  the  edge  of  the 
articular  surface  on  the  dorsum,  radii,  will  aid  in  demonstrating  the  presence  of 
the  line  of  fracture.     Crepitus  may  also  be  felt  in  the  majority  of  instances. 

Treatment. — Prof.  L.  S.  Pilcher's  method  of  reduction  is  as  follows:  With  the 
patient  fully  anesthetized  (nitrous-oxide  gas  will  suffice  in  the  majority  of  cases, 
although  in  alcoholics,  morphia  and  ether  may  be  required),  with  the  back  of  the 
patient's  hand  turned  upward,  the  operator  grasps  the  hand  and  foveann  so  that 
the  thumb  nails  of  the  two  hands  are  in  touch  immediately  over  the  line  of  fracture. 
The  patient's  hand  is  now  subjected  to  extreme  extension  by  bending  it  backward 
at  the  line  of  fracture  until  the  dorsum  of  the  hand  and  the  surface  of  the  anterior 
fragment  is  practically  at  right  angles  to  the  axis  of  the  forearm.  This  manipu- 
lation entirely  relaxes  the  heretofore  tense  fibroits  band  wMcli  has  prevented  reduc- 
tion, and  imlocks  any  partial  impaction.  If  now,  at  this  juncture,  the  thumb  of 
the  operator's  upper  hand  is  pushed  do'^vn  in  the  general  direction  of  the  back  of 
the  radius  until  it  comes  in  contact  with  that  which  is  holding  the  lower  fragment, 
this  pressure  will  slide  the  broken  piece  forward  to  its  position,  and  at  this  mo- 
ment the  patient's  hand  is  carried  into  its  normal  position. 

In  rare  instances,  where  the  impaction  is  severe  or  the  displacement  marked, 
it  may  be  necessan'  to  repeat  this  manceuvre. 

"Wlien  there  is  lateral  displacement,  this  should  be  corrected  while  the  hand  is 
held  at  right  angles  to  the  forearm,  and  before  the  fragment  is  finally  reduced  by 
flexion. 


Fig.  213. — Pli  r  >-    ing  tor  Collea'  fracture.    The  mitten  extends  an  inch  too  far  along  the 

fingers. 

The  application  of  a  plaster-of-Paris  mitten  (as  shown  in  Fig.  21.3)  is  an  ideal 
dressing  for  this  fracture;  the  thumb  and  fingers  are  left  free  so  that  they  may 
be  kept  in  motion  in  order  to  prevent  adhesion  of  the  tendons  to  their  sheaths  as 
they  pass  over  the  broken  end  of  the  radius.  If  plaster-of-Paris  may  not  be  had, 
a  posterior  board  splint,  properly  padded  and  long  enough  to  extend  from  the 
middle  of  the  forearm  to  the  end  of  the  metacarpal  bones  should  be  applied  and 
held  in  position  by  a  snugly  fitting  roller-bandage.  These  dressings  should  remain 
undisturbed  for  about  two  and  one  half  weeks  in  children,  and  from  three  to  four 
weeks  in  adults  and  elderly  persons. 

Carpus,  Metacarpus,  Phalanges. — Fractures  of  the  carpus  should  be  restored 
as  near  to  the  normal  position  as  possible,  and  immobilized  by  the  plaster-of-Paris 
mitten  figured  above. 

The  same  treatment  will  apply  to  one  or  more  of  the  metacarpal  bones,  the  ends 
having  been  carefully  placed  in  apposition. 

Fractures  of  the  phalanges  require  to  be  placed  accurately  in  position  and  held 
by  a  board  splint,  properly  padded.  It  is  frequently  advisalDle  to  couple  an  unin- 
jured finger  with  the  broken  member  in  order  to  use  it  as  lateral  support  to  hold 
the  splint  in  position. 

Sternum — Eihs — Vertelra?. — Fracture  of  the  sternum  is  rare.  It  may  be  recog- 
nized by  mobility  at  the  point  of  fracture  and  by  depression.  Dangerous  hemor- 
rhage from  the  internal  mammary  arteries  may  occur  when  great  violence  has  been 
inflicted.     Eeposition  may  be  effected  by  lifting  with  a  blunt  hook  or  an  elevator. 


166  THE   SURGICAL   DISEASES  AXD   SURGERY   OF   THE   BONES 

111  the  treatment  the  most  ijerfect  quiet  should  be  enforced.    Xo  siiecial  dressing  is 
required. 

The  ribs  or  their  cartilages  may  be  broken  by  direct  violence,  or  indirectly,  as 
by  a  blow  upon  the  sternum  or  crushing  between  the  sternum  and  the  spinal  column, 
or  from  muscular  contraction.  The  longer  ribs  are  most  liable  to  fracture,  and 
when  the  force  is  applied  to  the  sternum  the  break  most  frequently  occurs  just 
anterior  to  the  middle  of  the  bone.  The  displacement  is  usually  slight.  Htemor- 
rhage  from  rapture  of  the  intercostal  vessels  is  one  of  the  immediate  dangers,  while 
puncture  of  the  jaleura  or  lung  may  occasionally  result. 

A  diagnosis  is  based  upon  pain  elicited  by  pressure  at  a  point  remote  from  the 
fracture,  occasionally  by  a  peculiar  click  or  crepitus  felt  by  lajdng  the  hand  over 
the  injured  region  during  the  full  respiratory  act.  As  a  rule  the  respiratory  move- 
ment is  less  full  uf)on  the  affected  side. 

Treatment. — Fixation  of  the  chest  wall,  as  far  as  possible,  is  the  indication  in 
treatment.  This  may  be  secured  by  aj^plying  adhesive  strips,  cut  one  and  one  half 
inches  wide  and  long  enough  to  reach  from  the  sternum  to  the  vertebral  spines. 
These  should  be  tightly  applied  and  extend  far  enough  al)ove  and  below  the  broken 
rib  or  ribs  to  cover  the  three  or  four  adjacent  bones.  The  strij)s  should  overlap 
about  one  half  of  their  width. 

Vertebral  Column. — Fracture  of  the  vertebrce  frequently  occurs  from  indirect 
violence,  as  in  the  act  of  diving,  the  patient  striking  squarely  on  the  head,  or  by 
falling  from  a  height  and  striking  upon  the  feet  or  buttocks;  or  the  bodies  may 
be  crushed  by  extreme  flexion  or  extension,  or  by  direct  injury  with  or  without 
penetration.  The  character  of  the  injury,  the  displacement  of  the  spine,  pain,  and 
the  s^Tuptoms  of  jiressure  upon  the  cord,  or  nerves  will  aid  in  a  correct  diagnosis. 

Treatment. — When  the  sjanptoms  of  pressure  upon  or  injury  to  the  cord  or 
any  of  the  nerve  trunks  has  caused  paralysis  of  motion,  or  of  sensation,  immediate 
operation  is  advisable,  for  the  reason  that  when  the  cord  is  not  torn  or  divided, 
pressure  upon  its  sul)stance  from  depressed  bone  or  blood  clot  will  rapidly  lead 
to  degenerative  changes,  which  become  more  or  less  permanent,  whereas  if  the 
pressure  be  immediately  removed  these  changes  are  not  apt  to  occur.  If  the  oper- 
ation be  done  under  careful  asepsis,  the  dangers  are  slight,  especially  when  it  is 
not  necessary  to  open  the  dura.  When  several  months  have  elapsed  after  the 
injury  the  prognosis  after  operation  is  not  so  favorable ;  however,  in  several  in- 
stances ver}'  marked  improvement  has  followed  the  removal  of  depressed  bone. 

Operation — Laminectomy. — With  the  patient  in  the  prone  position,  reclining 
somewhat  upon  one  side  in  order  to  interfere  as  little  as  possible  with  respiration, 
an  incision  seven  or  eight  inches  in  length,  the  center  of  which  is  over  the  seat 
of  fracture,  is  made  directlj'  along  the  spines.  Strong  retraction  will,  in  great 
measure,  control  the  bleeding.  The  attachments  of  the  muscles  should  be  lifted  from 
the  bones  with  a  periosteal  elevator  when  possiljle,  in  order  to  avoid  wounding  any 
vessels.  Certain  attaclmients  will  need  to  be  divided  with  the  scissors.  When  the 
laminse  are  exposed,  one  of  these  should  be  divided  with  a  small  rongeur  and  re- 
moved with  others  until  the  dura  is  sufficiently  exposed.  If  de^Jressed  bone  has 
been  found  and  the  dura  has  not  been  penetrated,  it  may  not  be  necessary  to  proceed 
further.  Opening  into  the  dura  should  be  avoided  if  the  operator  is  satisfied  from 
careful  inspection  that  there  is  no  hemorrhage  within  the  dural  sac. 

If  it  be  deemed  necessary  to  proceed  further,  the  dura  should  be  opened  by  a 
sharp-pointed  knife,  cutting  carefully  in  the  middle  line  until  there  is  an  escape 
of  a  drop  or  more  of  clear  cerebrospinal  fluid.  Through  this  puncture  a  small 
dull-pointed  grooved  director  should  be  inserted,  and  the  dura  divided  exactly  in 
the  middle  line  as  far  as  necessary.  With  the  escape  of  fluid  the  edges  of  the 
dura  can  be  held  apart  by  a  mouse-tooth  forceps  and  the  cord  inspected.  A  small - 
dull-pointed  silver  probe  may  be  passed  up  and  do^Ti  from  this  point  of  opening, 
to  determine  wlietlier  or  not  there  is  compression  from  depressed  bone. 

The  dura  should  be  closed  by  fine  interrupted  catgut  sutures  passed  about  three 
sixteenths  of  an  inch  apart.  The  muscles  should  be  brought  back  into  position 
by  ten-day  catgut  sutures.  Silkworm-gut  sutures  are  used  for  the  skin  by  the  sub- 
cuticular or  interrupted  method.     It  is  a  wise  precaution  to  leave  a  few  strands 


THE  SURGICAL  DISE.A^ES  AND  SURGERY  OF  THE  BOXES      167 

of  catgiit  as  a  capillary  drain  from  the  most  dependent  angle  of  the  closed  dura, 
comiag  out  at  the  lowest  angle  of  the  ■wound. 

The  patient  should  remain  upon  the  back  for  the  fii-st  vreek  or  ten  days  after 
the  operation.  Dressings  may  be  changed  on  the  tliird  or  fourth  day,  or  whenever 
necessary. 

Eemoval  of  the  lamina  of  two  or  three  vertebra;  seems  to  cause  no  inconvenience 
to  patients  after  their  complete  recover}-. 

The  operation  just  described  gives  the  best  results  when  the  lamiuse  or  the 
articular  or  transverse  processes  have  been  fractui-ed  and  are  impinging  upon  the 
cord.     Fractures  of  the  bodies  of  the  vertebrte  rarely  cause  compression. 

In  crushiugs  of  the  bodies,  extension  of  the  spinal  column,  by  placing  the 
patient  in  bed  upon  the  back  with  cusliions  or  pillows  immediately  under  the  broken 
point,  wUl  secure  the  fullest  possible  extension  and  the  most  complete  rest  wiiile 
the  process  of  repair  is  taking  place. 

In  any  of  these  lesions  of  tlie  spinal  column,  when  for  any  reason  operation 
is  not  performed,  the  patient  sliould  be  put  to  bed  with  carefully  adjusted  exten- 
sion and  counter-extension  made  from  the  head  and  thighs.  Every  care  should 
be  taken  to  prevent  pressure  sores  on  the  back,  bitttocks,  and  heels,  and  when 
paraplegia  is  j)i'esent  strict  aseptic  care  in  relieving  the  bladder  is  essential.  When 
recovery  is  sufficient  to  justify  the  upright  posture,  the  SaiTe  plaster-of-Paris 
jacket  or  the  Scliaffer  brace  may  be  applied. 

Fracture  of  the  articular  process  is  of  less  freqttent  occurrence.  It  may  result 
from  extreme  dorso-lateral  extension  or  from  direct  violence. 

When  the  spinous  processes  are  broken  the  lesion  may  occur  near  the  extremity, 
but  more  frequently  the  lamins  are  involved. 

Sacrum  and  Coccy.r. — Fractures  of  the  sacrum  are  rare,  and  are  caused  by 
direct  violence,  usually  by  penetrating  bodies  or  falls  from  a  height  so  great  that 
other  and  serious  complications  render  the  prognosis  grave.  Enforced  quiet,  the 
arrest  of  hemorrhage  and  replacement  of  the  broken  fragments  when  tliis  is  pos- 
sible, are  the  indications. 

Fracture  of  the  coccyx  with  forward  displacement  is  common,  the  accident 
occurring  from  a  fall  or  blow  directly  upon  the  tip  of  the  spine.  The  si-mptoms 
are  pressure  upon  the  rectum,  causing  at  times  difficult}"  in  defecation,  and  more 
or  less  pain  from  pressure,  not  only  upon  the  bowel,  but  upon  the  fifth  sacral  and 
coccygeal  nerve. 

Treatment. — Eemoval  of  this  bone  is  the  only  way  of  obtaining  permanent  re- 
lief from  these  painful  symptoms.  The  incision  is  made  directly  over  the  bone 
in  the  median  line,  the  muscular  attaclunents  being  closely  divided.  Care  must 
be  taken  to  avoid  wounding  the  posterior  hemorrhoidal  plexus  of  veins  or  the 
rectum. 

Os  Innominatum. — ^The  ilium,  iscliium,  or  pubes  may  be  broken  singly,  or  in 
rare  instances  tlie  three  bones  may  be  involved  in  a  common  lesion.  Fracture 
in  the  acetabulum  may  be  caused  by  a  fall  on  the  foot  or  great  trochanter,  the 
head  of  the  femur  being  driven  violently  into  the  socket,  or  by  violence  directly 
applied. 

Wlien  the  iliac  crest  is  broken  the  diagnosis  may  be  determined  by  the  mobility 
of  the  fragment,  with  crepitus  and  pain.  When  more  deeply  situated,  digital  ex- 
ploration by  the  rectum  or  vagina  may  be  necessary  to  determine  the  line  of  frac- 
ture. Bloody  urine,  drawn  by  catheterization,  is  strongly  iudicative  of  fracture 
with  perforation,  and  this  condition  demands  immediate .  operation.  When  the 
intestinal  tract  is  perforated  shock  is  usually  present  and  peritonitis  rapidly  de- 
velops.   The  X-ra}'  should  be  used  on  all  occasions. 

The  treatment  demands  reposition,  as  far  as  possible,  and  complete  rest.  When 
the  acetabulum  is  involved,  extension  from  the  lower  portion  of  the  femur  and 
counter-extension  by  elevating  the  foot  of  the  bed  (Buck's  method),  should  be 
practiced.  It  is  advisable  to  have  the  bed  so  arranged  that  defecation  may  be 
accomplished  witliout  lifting  the  pelvis :  a  modification  of  Crosby's  fracture  bed 
would  answer  this  purpose.  Fixation  of  one  or  both  thighs,  including  the  pelvis 
and  lower  portion  of  the  spine  and  abdomen,  can  be  secured  by  a  plaster-of-Paris 


168 


THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE  BONES 


spiea.  The  prognosis  will  depend  in  great  measure  upon  the  extent  of  the  injury 
sustained  by  the  pelvic  viscera.  Eupture,  not  only  of  the  bladder,  but  of  the  deep 
urethra  is  an  occasional  complication. 

Intra-peritoneal  rupture  will  require  suture,  and  a  careful  toilet  of  the  pelvic 
peritoEEeum,  with  suprapubic  drainage  when  necessary.     After  suture  of  the  blad- 


-Wyeth's  drills  with  adjustable  handl 


nt  exsection. 


der  in  men,  it  is  a  wise  precaution  to  drain  for  a  week  or  ten  days  through  the 
deep  urethra  and  perinaeum;  in  females  a  catheter  introduced  through  the  urethra 
may  be  left  in  place. 

Femur. — Fractures  of  the  neck  of  this  bone  may  be  intra-  and  extra-capsular, 
or  partially  within  and  without  the  capsule.  The  extra-capsular  variety  may  in- 
volve one  or  both  trochanters. 

Fractures  of  the  femur  are  clinically  divided  into  three  groups,  viz.:  (1)  of 
the  upper  extremity,  including  the  neck  and  trochanter,  (2)  of  the  shaft,  (3) 
of  the  lower  or  condyloid  extremity. 

In  fracture  of  the  neck  of  the  femur,  the  line  of  cleavage  may  lie  wholly  within 
or  without  or  partly  within  and  partly  without  the  capsule.  In  children  and  young 
adults  there  may  occur  (though  rarely  unless  in  hip  disease)  an  epiphyseal  separa- 
tion. Fractures  of  the  neck  are  apt  to  be  complete  in  elderly  persons,  but  not 
infrequently  they  are  partial  or  impacted  in  children  and  others  under  forty  years 
of  age.    The  Roentgen  ray  has  demonstrated  that  this  fracture  is  much  more  eom- 


FiG.  215. — Impacted  fracture  of  the  neck  of  the  femur  partly  within  and  without  the  capsule.     United. 
About  three  fourths  inch  shortening.     Male,  about  forty-five  years  of  age. 

mon  in  children  and  young  adults  than  was  formerly  suspected  (Whitman).  In 
the  old  it  is  due  to  the  common  condition  of  rarefaction  in  bone,  which  begins 
about  the  fiftieth  year  of  life,  and  to  the  change  in  the  relation  of  the  axis  of 
the  neck  to  that  of  the  shaft,  the  angle  being  less  oblique  and  the  bone  therefore 


THE   SUEGIC-U.   DISEASES  .\XD   SURGERY   OF   THE   BOXES 


169 


less  able  to  stand  a  sudden  impact  from  above.  It  is  usually  caused  by  a  force 
transmitted  from  below  upward  along  the  shaft  of  the  femur.  In  many  instances 
with  the  aged  the  cause  is  trivial,  as  in  the  act  of  kneeling  or  even  wliile  turning 
in  bed.     It  also  occurs  from  direct  violence,  as  ia  a  fall  upon  the  trochanter. 

Diagnosis.— If,  after  a  fall  upon  the  foot  or  Imee  or  directly  upon  the  tro- 
chanter, there  results  pain  in  the  hip  with  eversion  of  the  foot,  shortening,  loss 
of  function  with  or  without  crepitus,  fracture  is  probable.  All  of  these  symptoms, 
however,  are  not  always  present.  Pain  is  the  most  constant,  together  with  eversion 
unless  impaction  has  occurred.  The  outward  rotation  is  due  in  part  to  gravity,  but 
chiefly  to  contraction  of  the  powerful  external  rotators  at  the  hip  (Fig.  216). 
Shortening  is  present  practically  in  all  eases,  with  or  without  impaction.  It  is  de- 
termined by  comparative  measurement  of  the  two  sides,  from  the  anterior  superior 
spiae  of  the  ilium  to  the  inner  malleolus.    The  internal  malleoli  should  be  made  to 


Fig.  216. — Showing  the  displacement  of  the  fragments 
(.ifter  Graj'.) 


fracture  of  the  neck  of  the  femur. 


touch,  and  should  be  directly  in  a  line  with  the  symphysis  pubis,  umbilicus,  and  in- 
terclavicular notch.  The  end  of  the  tape  should  be  held  on  the  thumb  nail,  and 
pressed  well  into  the  notch.  Just  imder  the  anterior  superior  spine.  It  is  then  car- 
ried along  the  inner  side  of  the  thigh,  knee,  and  leg,  to  the  under  edge  of  the  inner 
malleolus.  The  degree  of  shortening  will  vary  from  one  fourth  of  an  inch  up  to  two 
or  more  inches.  The  occasional  normal  inequalit}'  in  the  length  of  the  two  lower 
extremities  should  be  remembered.  To  determine  that  the  shortening  is  between 
the  trochanter  and  the  acetabulum,  apply  Kelaton's  test;  a  line  drawn  from  the 
tuberosity  of  the  ischium  to  the  anterior  superior  spine  of  the  ilium  passes  over  the 
upper  surface  of  the  .great  trochanter.  The  distance  the  tip  of  the  trochanter  may 
be  above  this  line  will  give  the  degree  of  shortening.  Bryant's  test  is,  with  the 
patient  resting  upon  the  back,  the  legs  parallel  and  extended,  to  drop  a  line  from 
the  anterior  superior  spine  and  to  measure  the  distance  between  this  Une,  at  its 
nearest  point  to  the  trochanter  and  this  tuberosity.  If  the  fracture  is  above  the 
trochanter  the  tuberosity-  will  be  found  nearer  the  line  than  on  the  sound  side. 
Crepitus  is  absent  with  impaction,  and  is.  in  fact,  not  essential  to  a  dia,gnpsis. 

In  all  the  outward  dislocations,  in  addition  to  immolility  there  is  inversion 
of  the  foot.  In  the  rare  thT,-roid  or  pubic  variety,  the  displaced  head  of  the  bone 
is  easily  recognized. 


170  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 

I-oss  of  function  does  not  always  occur,  for  in  some  instances  with  firm  im- 
paction tlie  patient  iias  been  linown  to  walk  nnaided  a  considerable  distance. 

The  prognosis  after  this  formidable  injury  should  always  b.e  guarded.  The 
result  depends  in  large  measure  upon  the  age  and  condition  of  the  patient,  the 
exact  location  of  the  line  of  cleavage,  the  prompt  recognition  of  the  lesion  and 
appropriate  treatment.  In  practically  all  cases  the  function  of  the  joint  is  never 
performed  so  satisfactorily  after  as  before  the  injury.  There  must  of  necessity  be 
shortening,  and  should  solid  union  be  obtained  the  inequality  in  length  of  the  lower 
extremities  will  need  to  be  corrected  by  the  elevation  of  the  sole  of  the  shoe  on 
the  short  side  to  ijrevent  muscular  strain  and  spinal  curvature.  In  the  very 
old  and  infirm,  and  in  heavy  obese  individuals,  absorption  of  the  upper  fragment 
occurs  with  loss  of  one  or  two  inches  in  length,  and  a  lameness  which  necessitates 
the  use  of  crutches  or  of  some  artificial  supj^ort.  In  a  certain  proportion  of  cases 
death  ensues  from  shock,  while  others  condemn  themselves  to  the  lifelong  imprison- 
ment of  a  chair  or  the  bed  on  account  of  timidity. 

By  reason  of  the  increased  blood  suppl_y  the  prognosis  is  more  favorable  as  the 
line  of  fracture  approaches  the  trochanter.  In  children  and  adults,  with  prompt 
recognition  of  the  character  of  the  lesion,  by  means  of  the  Roentgen  ray,  and  the 
institution  of  proper  treatment,  a  fairly  satisfactory  restoration  of  function  with 
the  minimum  of  shortening  may  be  expected. 

Treatment. — In  the  old  and  feeble,  where  operative  intervention  is  contra- 
indicated,  that  plan  of  treatment  which  will  give  the  minimum  of  discomfort 
should  be  instituted.  Extension  and  counter-extension  are  only  indicated  for  the 
relief  of  pain  due  to  muscular  spasm.  At  times  it  will  suffice  to  apply  long,  nar- 
row bags  of  sand  to  the  side  of  the  thigh  and  leg,  holding  the  extremity  as  near 
the  normal  position  as  possible.  Should  extension  be  required.  Buck's  method  is 
advised,  and  to  this  may  be  added  the  long  splint  of  Hamilton  if  needed.  Its  appli- 
cation is  given  on  another  page. 

Fracture  of  the  neck  of  the  femur  in  an  aged  person  who  is  otherwise  in  good 
physical  condition  should  be  treated  hy  immobilization  with  the  gypsvim  dressing, 
and  to  this  may  be  added  in  projDcrly  selected  cases  the  operation  of  spiking  the 
fragments  together.  Bony  union  and  a  fair  restoration  of  function  is  possible 
in  a  certain  proportion  of  cases  which  under  less  efficient  methods  have  heretofore 
been  condemned  to  a  crutch  or  cane. 

The  operation  of  spiking  is  done  as  follows:  With  the  patient  placed  in  the 
proper  position  of  extension  and  counter-extension  and  anresthetized  upon  a  suit- 
able operating  table  (preferably  Downey's  (Fig.  217),  or,  if  this  is  not  available, 
T.  H.  Hancock's  apparatus  for  the  application  of  the  complete  plaster-of-Paris 
dressing),  an  incision  is  made  exposing  the  great  trochanter.     The  dissection  is 


Fig.  217. — Plaster-of-Paris  dressing,  extension,  counter-extension  and  abduction  done  mechanically  by 
Downey's  operating  table. 

only  continued  far  enough  to  enable  the  operator  to  determine  the  exact  direction 
of  the  neck.  The  thigh  is  then  well  abducted  and  rotated  slightly  inward  until 
the  foot  assumes  the  normal  position.  If  the  fluoroscope  is  at  hand,  the  surgeon 
should  by  its  use  satisfy  himself  of  the  alignment  of  the  two  fragments,  and 
while  thus  held  the  author's  drill   (Fig.  214)   is  inserted  through  the  trochanter. 


THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 


171 


in  line  with  the  general  direction  of  the  neck,  and  carried  in  until  b}'  accurate 
measurement  it  is  determined  that  the  point  of  the  drill  has  passed  into  the  distal 
fragment  and  liead  of  the  bone.  The  liandle  of  the  instrument  is  now  unshipped 
and  the  drill  left  in  place,  with  the  end  of  the  shaft  projecting  slightly  beyond  the 
skin  incision,  which  is  closed.  A  light  gauze  dressing  is  applied,  the  extremity 
is  adducted  to  its  normal  relation  to  the  body  and  its  fellow,  and  the  plastor-of- 
Paris  immobilization  at  once  effected. 

The  drill  should  be  extracted  without  removing  the  plaster-of-Paris  dressing 
about  the  end  of  the  fourth  week.  This  can  readily  be  done,  as  the  end  projects 
beyond  the  skin  and  can  be  exposed  by  cutting  away  a  small  circle  of  the  gypsum. 
At  the  end  of  the  sixth  week  the  plaster  from  the  knee  down  should  be  removed, 
and  passive  motion  made  of  this  joint  and  the  ankle.  In  two  weeks  more  the  cast 
may  be  discarded,  but  the  hip  should  be  carefull}'  guarded  for  two  or  three  months. 
In  senile  cases,  where  it  has  not  been  deemed  advisable  to  use  the  drill  or  the 
gypsum  method,  the  period  of  quiescence  should  be  determined  by  individual  com- 
fort. In  general,  the  sooner  this  class  of  patient  is  up  and  about  the  better,  as 
there  is  a  strong  tendency  to  become  bedridden. 

In  all  cases  in  children  and  young  adults,  the  method  of  Dr.  Eoyal  Whitman 
is  advised.  It  is  practically  as  follows:  The  chest,  abdomen,  and  extremity  of 
the  injured  side  are  fitted  with  muslin 
imdershirting.  The  patient,  fully  anies- 
thetized,  is  placed  on  the  table,  rigged 
with  a  sacral  and  shoulder  support 
for  applying  a  complete  plaster-of- 
Paris  dressing.  Counter-extension  is 
made  from  the  crotch  and  perina?um 
and  extension  directly  from  the  leg 
and  foot.  The  limb  under  gentle  trac- 
tion is  slowly  abducted,  an  assistant 
at  the  same  time  abducting  the  sound 
limb  to  prevent  the  tilting  upward  of 
the  pelvis.  If  the  fracture  is  complete, 
the  shortening  is  first  entirely  over- 
come by  the  traction  and  counter- 
traction.  The  limb  in  the  extended 
attitude,  imder  traction,  is  slowly  ab- 
ducted by  the  assistant  until  the  tro- 
chanter is  fairly  apposed  to  the  side 
of  the  pelvis,  the  operator  meanwhile 
pressing  the  trochanter  downward  and 
inward   (Fig.  218).     In  some  instances 

there  is  a  distinct  snap  as  the  outer  part  of  the  neck  slips  beneath  the  rim  of 
the  acetabulum.  The  primary  object  of  the  abduction  is  by  leverage  against  the 
iipper  border  of  the  acetabulum  to  overcome  the  deformity;  the  second  is  by  tension 
on  the  capsule  to  remove  folds,  to  appose  the  fragments  and  to  oppose  redis- 
placement. 

The  limb  being  held  in  this  attitude,  the  pelvis,  the  ribs,  the  bony  prominences 
of  the  knee  and  foot  are  protected  with  layers  of  sheet  wadding,  and  the  limb  and 
l)ody  are  covered  in  carefully  with  cotton  iiannel  bandages.  A  plaster  spica  is  then 
applied,  extending  preferably  from  the  mammary  line  to  the  toes.  This  should 
be  drawn  snugly  al}out  the  hip,  and  most  important  of  all,  should  completely  en- 
close and  support  the  buttock,  not  only  to  provide  antero-posterior  support,  but  to 
prevent  the  excoriations  that  are  inevitable  if  the  tissues  are  allowed  to  hang  over 
the  edge  of  the  plaster.  The  insertion  of  thin  strips  of  wood  or  iron  about  the 
hip  and  knee  permits  of  a  lighter  bandage  than  would  otherwise  be  possible.  When 
the  bandage  is  completed  it  is  carefully  cut  away  to  allow  complete  flexion  of  the 
sound  limb,  the  shirting  is  drawn  over  the  edges  of  the  bandage,  carrying  beneath 
it  the  cotton,  and  is  sewed  preferably  to  an  outer  cover  of  sMrting  drawn  over  the 
bandaare. 


Fig.  218. — Whitman's  position.  Reduction  and 
fixation  in  abduction,  showing  security  from 
direct  bony  contact  of  the  neck  and  trochanter 
with,  the  pelvis,  also  the  effect  of  this  position 
on  muscular  action.  A,  Abductor  group.  Bj 
ilio-psoas.     C,  capsule.      (.After  Wliitman.) 


172 


THE   SURGICAL   DISEASES  AND    SURGERY   OF   THE   BONES 


Tor  greater  precaution  it  may  be  advisable  to  cut  openings  in  tbe  plaster  at 
all  points  where  pressiire  is  feared,  and  a  part  may  be  cut  away  from  the  front 
of  the  body  part  if  the  constriction  is  too  great  (Fig.  219).  At  the  end  of  four 
weeks  the  plaster  cast  should  be  removed  from  the  knee  down,  to  pemiit  move- 
ments in  this  joint  and  the  ankle,  and  at  the  end  of  eight  weeks  the  entire  gyp- 


FlG.  219. — Wliitman's  position.  The  long  spica  as  applied  for  fracture  of  the  neck  of  the  femur  in  the 
adult;  illustrating  the  advantage  of  an  appliance  which  permits  movement  without  danger  of  dis- 
placement of  fragments;  an  opening  has  been  made  to  lessen  the  constriction  of  the  abdomen. 
(After  Whitman.) 

sum  cast  is  discarded.  The  limb  sliould  not  be  used  to  support  weiglit  for  at  least 
four  months.^ 

Fractures  through  the  trochanters  are  veiy  often  partially  or  completely  im- 
pacted. For  this  reason  crepitus  may  be  absent  (Fig.  215).  Whether  or  not 
impaction  has  occurred  rotation  outward  is  not  so  marked  a  feature  of  this  frac- 
ture as  of  that  which  occurs  through  the  neck.  The  absence  of  the  symptoms  of 
dislocation,  together  with  shortening  and  pain,  should  determine  the  diagnosis. 

Fracture  of  the  femur  at  tliis  level  is  occasionally  met  with  in  the  new-born, 
and  is  caused  by  traction  on  the  flexed  thigh  in  breach  presentations,  the  bone 
breaking  near  the  level  of  the  lesser  trochanter.  In  this  particular  fracture  (at 
or  immediately  below  the  lesser  trochanter)  there  is  even  in  adults  a  marked  tilt- 
ing forward  or  flexion  of  the  upper  fragment  (with  external  rotation)  due  to 
contraction  of  the  psoas  and  iliacus  muscles,  with  outward  rotation  caused  by  the 
action  of  the  powerful  external  rotators  (Figs.  220  and  216). 

This  is  much  more  marked  in  the  newly  born  for  the  reason  that  the  psoas 
and  iliacus  muscles  have  never  been  stretched.  In  treatment  with  plaster-of-Paris 
around  the  extremity  and  abdomen  the  proper  position  is  to  flex  the  thigh  well 
upon  the  abdomen  -with  slight  outward  rotation  and  abduction.-  In  adults  flexion 
at  about  forty-five  degrees,  with  slight  abduction,  will  suffice  and  will  generally 
be  the  position  of  least  discomfort  to  the  patient,  giving  a  satisfactory  result  if 
extension  and  counter-extension  are  maintained  while  the  plaster-of-Paris  is  setting 
(Fig.  221). 

Fractures  at  the  middle  of  the  femur  and  for  the  next  six  or  eight  inches 
below,  may  be  treated  in  the  straight  position  with  the  thigh  and  leg  in  the  axis 
of  the  body,  although  there  is  no  special  objection  to  the  position  of  partial  flexion 
which  has  been  advised  in  treating  fractures  above  the  middle.     Below  this  point 

1  Dr.  Royal  Whitman,  "Med.  Record,"  March  10,  1904. 

^  The  author  has  treated  one  case  of  this  fracture  at  birth  by  this  method  with  perfect  success, 
the  patient  being  now  twenty  years  old,  fully  developed  and  with  lower  extremities  of  equal  length, 
A  similar  experience  has  been  reported  by  Dr.  Edgar  Wilkinson,  a  distinguished  practitioner  of 
Bermuda. 


THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 


173 


and  including  the  condyloid  fractures,  the  straight  position  parallel  with  the  axis 
of  the  body  and  without  abduction  is  in  general  preferable.  The  gypsum  dressing 
should  be  applied  in  full  narcosis,  with  strong  extension  and  counter-extension 
continued  until  plaster  is  hard.  Mechanical  extension  is  much  more  satisfactory 
than  that  by  hand  (Fig.  217). 

While  it  may  not  be  absolutely  necessary  in  every  case  of  fracture  at  or  below 
the  middle  of  the  femur  to  apply  the  plaster-of-Paris  dressing  from  the  foot  and 
around  the  body  as  high  as  the  line  of  the  nipples,  it  should  come  at  least  as  high 
as  the  navel.  One  very  considerable  advantage  in  the  plaster-of-Paris  dressing 
is  that  it  permits  the  patient  after  three  weeks  to  be  up  and  about  on  crutches. 

When  the  fracture  line  approaches  the  Imee- joint  (within  about  five  inches) 
and  the  patient  declines  an  anfesthetic,  the  position  of  flexion  will  be  found  advan- 
tageous, since  it  reduces  muscular  resistance  to  the  minimum.  With  strong  ex- 
tension and  counter-extension,  aided  by  direct  pressure  forward  of  tlie  lower  frag- 
ment and  counter-extension  on  the  upper,  tlie  broken  ends  may  be  brought  into 
accurate  position  (Fig.  231).  The  action  of  the  muscles  which  cause  displacement 
in  this  fracture  are  shown  in  Fig.  224. 

When  in  a  fracture  in  any  portion  of  the  thigh  an  anesthetic  may  or  may  not 
be  employed,  and  the  gypsum  dressing  cannot  be  iitilized,  Buck's  extension  with 
Hamilton's  long  si^lint  (Fig.  222)  may  be  substituted.     It  is  applied  as  follows: 
Place  the  patient  upon  a  hard  mattress.     If  the  bed  is  too  soft  and  yielding, 
place  wide  boards  underneath  the  top  mattress  in  order  to  hold  it  smooth  and  firm. 
Elevate  the  foot  of  the  bedstead  from  six  to  ten 
inches  by  placing  the  legs  at  this  end  upon  blocks 
of   wood   or   bricks.      Cut   two    strips   of   strong 
adhesive  plaster    (Maw's  moleskin  is  preferable) 
about  two  inches  wide  and  long  enough  to  ex- 
tend from  the  hip  to  beyond  the  sole.     Lay  one 
of  these  upon  the  inner  and  outer  surface  of  the 
thigh  and  leg,  exactly  opposite  each  other,  and 
hold  them  in  place  by  a  well-adjusted  roller.   The 
strips   can   be   more    nicely   applied   if   they   a.re 
partially  divided  with  the  scissors  in  a  direction 


Fig.  220. — Displacement  of  fragments 
in  fracture  of  the  thigh  in  the  up- 
per third.     (After  Gray.) 


Fig.  221. — Mechanical  extension,  counter-extension  with 
sliglit  abduction,  and  gvpsum  dressing  with  Downey's 
table. 


upward  and  inward,  at  intervals  of  about  two  inches.  Six  inches  below  the  knee 
the  bandage  is  interposed  between  the  strips  and  the  integument,  for  no  traction 
should  be  made  from  the  leg.  In  order  to  prevent  pressure  upon  the  malleoli,  a 
stick  about  six  inches  in  length  is  placed  between  the  ends  of  the  adhesive  strips. 


174 


THE   SURGICAL   DISEASES  AND   SURGERY   OF  THE   BONES 


and  the  extension  weight  is  attached  to  this.     It  is  intended  hy  this  metliod  to 
make  the  traction  from  tlie  fcnmr  and  not  from  tlie  leg. 

A  piece  of  board  jH'ovided  with  a  pulley  is  next  fastened  to  the  foot  of  the 
bed,  so  that  the  tip  of  the  pulley  will  he  on  a  level  with  the  malleoli.  The  weight 
will  vary  from  two  or  three  up  to  eighteen  pounds.    A  pound  for  every  year  of  life 


Fig.  222. — Combination  of  Buck's  extension  and  Hamilton's 
long  splint. 


up  to  eighteen  is  the  rule;  but  this  is  too  much  for  fracture  above  the  trochanter. 
About  ten  pounds  is  sufficient  for  all  ordinary  cases.  Shot  in  a  bag,  or  smoothing- 
irons,  are  iisually  employed  for  the  extension  weight,  ivhich  is  tied  to  the  string 
(Fig.  223).  The  patient's  body  serves  as  the  counter-extending  force,  the  gravi- 
tation toward  the  head  of  the  bed  being  about  counteracted  by  the  weight  attached 
to  the  foot.  Additional  benefit  and  comfort  may  be  ol> 
tained  by  laying  small,  long  bags,  filled  with  sand,  on  ,   j,       . 


Fig.  223. — Emergency  apparatus  for  swinging  tlie  pelvis  in  applying 
gypsum  dressing  in  fracture  of  the  thigh  from  the  middle  to  the 
knee-joint. 


Fig.  224. — Displacement  of 
fragments  in  fracture  of 
the  tliigh  in  the  lower 
third.      (After  Gray.) 


either  side  of  the  thigh  and  leg.  "When  the  limb  tends  too  strongly  to  outward 
rotation  (or  inversion)  this  may  be  corrected  by  the  sand-bags,  or  by  Professor 
Hamilton's  long  splint,  which  is  shown  in  Fig.  222,  and  which  is  tied  by  strijjs 
of  bandage  from  the  axilla  to  the  ankle.  The  foregoing  is  practically  Buck's 
extension,  to  which  may  be  added  Hamilton's  long  splint. 


THE   SURGICAL   DISEASES  AND   SURGERY   OF  THE   BONES 


175 


In  some  instances  it  ma}'  be  found  advantageous  to  use  Vollcmann's  sliding 
foot  piece,  seen  in  Fig.  225.  Tliis  consists  of  a  posterior  splint  for  the  leg,  to 
which  is  attached  a  foot  piece  having  the  angle  sho'mi  in  the  cut.     This  splint 


Fig.  225  — A  olkniami'a  blidmg  foot  piece 


sliould  be  perforated  for  the  heel,  and  rest  upon  two  cross-bars  of  wood,  which  in 
turn  slide  up  and  down  on  a  rectangular  frame.  Upon  the  upper  edge  of  these 
parallel  bars  a  tongue  is  cut,  and  a  corresponding  notch  or  groove  in  the  cross- 
bars. 

In  order  to  prevent  the  bedclothing  from  coming  in  contact  with  the  fractured 
limb,  a  wire  screen  (Fig.  226)  may  be  employed. 

Patella. — Fracture  of  the  knee-pan  is  usually  caused  by  violent  contraction  of 
the  quadriceps  extensor  muscle,  while  the  leg  is  in  extreme  flexion.     It  may  be 


Fig.  226. — Wire  screen.     (.-Vfter  Esniarcli.) 

broken  by  a  direct  blow  or  a  fall  on  tlie  knee,  or  a  IjIow  and  muscular  action  may 
combine  to  break  it.  The  line  of  fracture  is  usually  transverse  or  nearly  so  just 
below  the  middle  of  tlie  bone,  although  it  may  break  above  or  lielow  this  plane.  It 
is  occasionally  split  longitudinally  b}'  direct  violence,  or  it  may  be  comminuted. 
This  fracture  is  rarely  incomplete,  the  separation  of  the  fragments  varying  from  the 
smallest  fraction  of  an  inch  to  as  mucli  as  two  or  more  inches.  The  separation 
is  somewhat  wider  at  the  inner  than  the  outer  border.  It  occurs  in  the  majority 
of  instances  between  the  twentieth  and  fortieth  years  of  life,  and  in  males  more 
frequently  than  females.  Owing  to  its  superficial  location,  by  reason  of  the  de- 
pression between  the  separated  fragments,  the  diagnosis  is  easy.  Should  the 
separation  be  very  slight,  lateral  motion  of  one  fragment  upon  the  otlier  will  elicit 
crepitus. 

The  treatment  is  ojierative  or  non-oj)erative.  I'nder  strict  asepsis  and  careful 
technic,  tlie  former  is  preferable,  altliougli  in  a  large  i^roportion  of  cases  a  satis- 
factory result  will  he  oljtained  Ijy  tlie  latter. 

The  following  operation  is  advised:  After  thorough  cleansing,  the  upper  edge 


176  THE   SURGICAL   DISEASES  AND   SURGERY   OF  THE   BONES 

of  the  lower  fragment  having  been  located,  a  transverse  incision  is  made  one  fourth 
of  an  inch  below  this  line,  exposing  the  whole  length  of  the  broken  surfaces.  In 
order  to  turn  up  a  sufficient  skin  flap,  a  sliort  perpendicular  incision  may  be  made 
at  either  end  of  the  transverse  cut.  Tlie  clot  between  the  two  fragments  is  now 
removed,  preferably  by  irrigation  with  hot  salt  solution,  115°  or  120°  F.  Under 
no  circumstances  should  tlie  finger  be  introduced,  and  it  is  better  not  to  use  forceps 
or  gauze,  unless  tlie  latter  be  necessary  to  remove  any  excess  of  solution. 

Two  subcutaneous  sutures,  one  for  tlie  upper  and  one  for  the  lower  fragment, 
are  now  introduced  through  the  wound  beneath  the  flaps,  near  the  inner  border 
of  the  patella  at  tlie  line  of  fracture.  For  the  upper  one  of  the  two  loops,  the 
needle  is  made  to  emerge  tlirough  the  skin  at  a  point  just  above  the  upper  margin 
of  the  jiatella.  It  is  reintroduced  through  this  same  puncture,  and  carried  across 
tlie  upper  margin  of  the  patella  through  the  substance  of  the  tendon  of  the  quad- 
riceps extensor  muscle,  at  the  outer  limit  of  which  it  emerges  through  the  skin, 
to  be  again  reintroduced  through  the  hole  of  exit,  and  to  come  out  finally  in  the 
wound  lieneath  the  flap  at  the  outer  border  of  the  patella  at  the  line  of  fracture. 
The  inferior  loop  is  introduced  in  the  same  way,  its  transverse  piortion  passing 
through  tlie  substance  of  the  liganientum  patellae  at  the  lower  border  of  this  bone. 
Traction  upon  these  two  loops  brings  the  two  fragments  in  perfect  apposition. 
The  torn  edges  of  the  periosteum  are  now  carefully  everted  with  forceps,  and  re- 
united by  a  running  suture  of  very  fine  linen.  The  two  outer  and  inner  ends 
of  the  strong  linen  loop  sutures  are  now  tied,  as  the  fragments  are  pressed  very 
firmly  together.  The  superficial  wound  is  closed  with  sillavorm  gut,  the  line  of 
union  being  well  below  the  line  of  fracture.  A  light  sterile  gauze  dressing  and 
a  strong  plaster-of-Paris  cast  from  the  ankle  to  the  crotch  are  applied.  This  may 
be  fenestrated  over  the'  patella,  in  order  to  remove  the  superficial  sutures,  about 
the  tenth  day.  This  operation  may  be  done  with  jDerfect  satisfaction  under  cocaine 
infiltration. 

In  a  longitudinal  fracture  the  periosteal  sutures  only  are  necessary,  since  slight 
lateral  comjjression  with  adhesive  j)laster  will  hold  the  broken  surfaces  in  aj^po- 
sition.  AVhen  the  bone  is  comminuted  (stellate  fracture),  several  rows  of  periosteal 
sutures  may  be  required,  and  the  double  loof)  subcutaneous  suture  should  be 
employed.  When  muscular  rigidity  cannot  be  overcome  by  the  measures  just  indi- 
cated, the  complete  relaxation  of  ether  narcosis  will  be  necessary,  and  at  times 
the  insertion  of  silver  wire  through  drill-holes  will  be  required.  This  applies  espe- 
cially to  ancient  fractures  of  the  patella  in  which  there  is  a  wide  separation.  The 
drill  should  enter  about  one  half  of  an  inch  from  the  broken  edge,  and  pass  ob- 
liquely to  emerge  on  the  fractured  surface  well  above  the  joint  surface.  In  certain 
instances,  which  are  fortunately  extremely  rare,  in  order  to  secure  approximation 
in  widely  separated  fractures  of  long  standing,  the  subcutaneous  section  of  the 
quadriceps  extensor  tendon  and  the  contiguous  fascia  on  either  side  is  necessary. 

When  for  any  reason  the  suture  operation  may  not  be  done,  proceed  as  fol- 
lows :  Cut  a  piece  of  strong  adhesive  plaster  (moleskin  is  preferable,  or,  if  this 
cannot  be  obtained,  double  the  ordinary  adhesive  plaster)  about  ten  inches  in  length 
and  broad  enough  to  cover  the  whole  front  of  the  thigh,  fitting  snugly  above  the 
upper  limit  of  the  patella.  To  the  center  of  this  stitch  a  strong  piece  of  webbing 
about  an  inch  in  width  and  several  inches  in  length;  a  second  piece  of  plaster, 
somewhat  smaller  than  the  fijt'st,  is  applied  from  the  lower  limit  of  the  patella  and 
extending  down  the  leg  eight  or  ten  inches.  To  the  center  of  this,  at  the  middle 
of  the  liganientum  patella,  a  buckle  correspionding  to  the  size  of  the  tongue  of 
webbing  is  stitched  with  silk  thread.  With  the  leg  in  extension,  these  strips  of 
adhesive  plaster  are  bandaged  snugly  to  the  thigh;  by  passing  the  tongue  into 
the  buckle  and  pulling  upon  it,  the  fragments  are  not  only  closely  applied  to 
each  other  but  the  webbing  prevents  the  fragments  from  tilting.  The  whole  ex- 
tremity from  the  perinajum,  including  the  foot,  is  now  invested  with  plaster-of- 
Paris,  and  a  window  is  made  over  the  knee-joint  in  front  so  that  the  fracture 
may  be  kept  under  observation.  From  day  to  day  the  strap  may  be  tightened  as 
the  condition  of  the  patient  may  demand  (Fig.  227).  Should  the  cast  become 
loosened  by  shrinkage  of  the  limb,  a  strip  of  sufficient  width  should  be  cut  out 


THE  SURGICAL  DISEASES  AND  SURGERY  OF  THE  BONES 


177 


in  front  for  the  whole  length  of  the  cast,  and  an  ordinary  roller-bandage  applied 
to  make  it  fit  more  snugly.  In  this  way  the  action  of  the  quadriceps  extensor  is 
temporaril}'  paralyzed.  In  five  or  six  days  the  patient  may  move  about  carefully 
on  Clutches,  and  after  he  becomes  accustomed  to  the  use  of  these  he  can  walk 
about  and  attend  to  business  without  danger  to  the  limb.  This  dressing  should 
remain  undistuibed  for  from  eight  to  ten  weeks,  at  the  end  of  which  time  it 
should  be  removed,  and  while  the  fragments  are  held  closely  in  apposition  by  the 
liand  of  the  surgeon,  passive  motion  is  made  flexing  the  leg,  not  farther  than 
twenty-five  degrees  from  the  ant?rior  plane  of  the  thigh.  A  lighter  plaster  dress- . 
ing  is  then  applied,  and  the  patient  can  go  another  month  without  its  removal, 
when  the  same  passive  motion  is  repeated,  and  this  should  be  continued  for 
as  much  as  six  months  from  the  date  of  injury.  After  this  time  a  posterior 
splint    of    light    and    strong    shellac    board    or    leather    may    be    applied    in    the 

morning  and  removed  upon  going  to  bed, 
the  patient  going  about  with  the  aid  of 
a  cane.  The  atrophy  of  the  muscles  of 
the  thigh  and  leg  should  excite  no  con- 
cern. In  fact,  a  firm  ligamentous  union 
depends  in  good  part  upon  this  muscular 
atrophy.  The  functions  of  the  muscles 
and  of  the  joint  are  fully  reestablished  as 
soon  as  the  apparatus  is  left  aside  and  the 
patient  begins  to  use  the  limb.  The  essen- 
tial point  in  the  treatment  of  fracture  of 
the  patella  is  to  prevent  stretching  of  the 
ligament  or  fibrous  tissue  which  is  to  hold 
the  pieces  together,  and  if  this  is  properly 
attended  to,  a  union  will  be  obtained  of 
such  character  that  the  functions  of  the 
leg  will  be  practically  restored.  The  fail- 
ures which  have  occurred  in  the  treatment 
of  these  injuries  have  been  due  chiefly  to 
lack  of  appreciation  of  this  fact. 


Fig.  227. — Fracture 


Fig.  228. — Hamilton's  apparatu.-;  I'nr 
patella.      (Hamiltuii.) 


Wlien  tliis  apparatus  cannot  be  obtained,  the  method  employed  by  the  late  Frank 
H.  Hamilton  should  be  emploj'ed.    It  is  as  follows : 

A  posterior  splint  is  made  to  extend  from  near  the  heel  to  tlie  gluteal  fold. 
Shellac  board  is  best  suited  for  this  purpose,  but  sole  leatlier,  gutta-percha,  or  a 
piece  of  plank  will  suffice,  if  these  lighter  articles  cannot  be  obtained.  If  either 
of  the  first  three  articles  is  emploj'ed,  the  piece  should  be  cut  wide  enough  to 
envelop  from  one  half  to  two  thirds  of  the  circumference  of  the  limb.  Three  inches 
above  and  below  the  center  of  the  knee-joint  a  tongue,  one  inch  wide  and  two 
inches  long,  should  be  cut,  and  turned  out  so  that  the  attached  end  is  nearest  the 
joint.  This  splint  is  dipped  in  warm  water  until  soft  enough  to  be  molded  to  the 
part,  when  it  is  lined  with  a  sheet  of  absorbent  cotton  and  applied  on  the  posterior 


178  THE  SURGICAL  DISEASES  AND  SURGERY  OF  THE  BONES 

aspect  of  the  limb.  The  cotton  or  ijadding  material  should  be  considerably 
thicker  oijijosite  the  j^opliteal  space,  in  order  to  prevent  complete  extension  of  the 
leg.  Secure  the  upper  and  lower  ends  by  turns  of  the  roller  thrown  around  the 
thigh  and  leg,  and  next  begin  the  oblique  or  approximating  turns  by  carrying  a 
flannel  bandage  around  the  leg,  so  that  it  catches  behind  the  lower  tongue,  whence 
it  is  carried  obliquely  upward  above  the  upper  fragment,  across  the  quadriceps,  and 
back  to  the  starting-point.  This  is  continued  until  the  upper  fragment  is  brought 
into  apposition  with  the  lower.  For  the  lower  fragment  the  bandage  is  made  to 
catch  behind  the  upper  tongue  upon  the  splint.  When  the  fragments  are  approxi- 
mated the  entire  limb  is  invested  by  the  roller. 

After  the  dressing  is  applied  the  sanie  position  is  maintained  for  two  weeks. 
The  portion  of  the  bandage  immediately  over  the  fracture  should  be  opened  on 
the  fifth  or  sixth  day,  and  a  careful  insf)ection  made,  in  order  to  determine  whether 
the  roller  has  slij^ped  and  reseparation  occurred.  If  the  bandage  is  at  all  loose  it 
should  be  tightened,  but  never  drawn  so  tightly  that  it  produces  any  discomfort. 

This  inspection  should  be  repeated  every  five  or  six  days,  but  the  splint  is 
never  taken  oif  until  the  eighth  week,  when  passive  motion  at  the  knee-joint  should 
be  made. 

The  after-treatment  is  the  same  as  just  given. 

After  this  j^rocedure,  six  weeks  should  elapse  before  any  effort  at  flexion  is 
made.  At  this  time  the  plaster  cast  should  be  removed,  and  the  fragments  held 
firmiy  together  while  the  leg  is  bent  on  the  thigh  at  an  angle  not  beyond  twenty- 
five  or  thirty  degrees.  The  cast  should  be  readjusted  and  passive  motion  repeated 
weekly  for  the  next  four  weeks,  when  the  area  of  motion  may  be  gradually  in- 
creased to  and  beyond  ninety  degrees.  It  is  advisable  to  wear  a  protecting  cap  of 
sole  leather  or  shellac  board  for  several  months  to  prevent  the  possibility  of  acci- 
dent.    This  apparatus  may,  of  course,  be  removed  while  the  patient  is  in  bed. 

Leg. — Practure  of  one  or  botli  bones  of  the  leg  occurs  next  in  frequency  to 
that  of  the  radius,  the  clavicle,  and  ulna.  The  upper  end  of  the  tibia  is  usually 
broken  by  direct  violence,  although  a  fall  from  a  heiglit  upon  the  foot  may  produce 
a  longitudinal  or  oblique  fracture  communicating  with  tlie  joint.  The  separation 
sometimes  takes  place  through  the  epiphysis.  The  most  common  point  of  frac- 
ture is  the  junction  of  the  middle  and  lower  third.  The  fibula  may  be  broken  at 
the  same  level,  or  at  a  point  removed  from  the  line  of  fracture  in  the  tibia,  or  this 
last  bone  alone  may  be  brol^en. 

Near  the  ankle-joint,  partial  fracture  of  the  internal  malleolus  and  a  complete 
break  of  the  fibula  is  comparatively  frequent.  In  this  (Pott's)  fracture  (called 
also  railroad  or  street-car  fracture,  since  it  is  often  caused  by  jumping  from  a 
car  in  motion)  the  foot  is  powerfully  everted,  and  the  principal  strain  falls  upon 
the  internal  lateral  ligament  of  the  ankle-joint.  As  the  force  is  continued,  as  a  rule, 
a  crescent  of  bone  is  usually  torn  off  with  the  ligament,  or  the  entire  malleolus 
is  wrenched  off  at  a  higher  point.  The  pressure  upon  the  inner  aspect  of  tlie 
external  malleokis  forces  this  outward,  and  the  fibula  above  is  bent  inward  and 
usually  breaks  .about  two  or  three  inches  above  the  tip  of  the  malleolus.  If  great 
force  is  exercised  in  the  production  of  this  fracture,  the  inferior  tibio-fibular  liga- 
ment may  be  torn  away,  or,  more  likely,  the  outer  lip  of  the  articular  surface  of 
the  tibia  broken  off.  In  exceptional  instances,  inversion  of  the  foot  will  produce 
fracture  of  the  inner  malleolus  by  direct  pressure  of  the  astragalus,  and  of  the 
external  malleolus  or  fibula  by  traction  on  the  external  lateral  ligament. 

In  fracture  of  the  tibia  alone  the  displacement  will  be  determined  by  the  direc- 
tion of  the  line  of  fracture.  Marked  overlapping  or  displacement  is  prevented  by 
the  unbroken  fibula.  In  the  upper  portion,  with  a  transverse  fracture,  the  deform- 
ity is  slight.  At  the  lower  and  middle  third  the  obliquity  is  usually  consideraljle, ' 
and  from  below  upward  and  backward  (Fig.  229).  The  upper  fragment  is  tilted 
forward  by  the  action  of  the  quadriceps  extensor,  and  partly  by  the  pressure  of 
the  upjDcr  end  of  the  lower  fragment,  which  is  thrown  in  the  same  direction  by 
the  contraction  of  the  sural  muscles  and  the  consequent  lifting  of  the  heel.  The 
deformity  in  Pott's  fracture  is  shown  in  Fig.  230.  In  complete  fracture  of  both 
bones  of  the  leg,  overlapping  and  displacement  are  the  rule. 


THE  SURGICAL  DISEASES  AND  SURGERY  OF  THE  BONES 


179 


Diagnosis. — Fracture  of  the  fibula  alone  may  exist  without  detection  unless 
the  X-ray  is  employed.  A  careful  examination,  with  direct  j^i'ossure,  will  usually 
elicit  crepitus  or  reveal  the  point  of  fracture  by  abnormal  mobility  and  pain. 
Fracture  of  the  tibia  is  easily  made  out  by  palpation  along  the  spine,  crepitus, 
loss  of  symmetry,  and  pain.  These  sjanptoms,  together  with  the  history  of  the 
accident,  will  leave  little  room  for  doubt  in  any  case.  Pott's  fracture  is  recognized 
by  the  peculiar  eversion  of  the  foot,  the  abnormal  prominence  of  the  internal  mal- 
leolus, pain,  and  loss  of  function.  Crepita- 
tion of  the  fragments  of  the  malleoli  may 
rtyysa       _  be    elicited,    and    preternatural    mobility    of 

B||Jf  the  fibula,   at  a  point  two  or   three   inches 

above  the  tip  of  the  outer  malleolus,  is  pres- 
ent. In  inversion  of  the  foot  with  fracture 
the  outer  malleolus  is  prominent.  Fracture 
of  both  bones  is  easily  made  out  by  the  de- 
formity, abnormal  mobility,  and  crepitation. 


Fig.  229. — Displacement  of  fragments  in  frac- 
ture of  the  tibia,  near  the  junction  of  the 
lower  and  middle  third.      (After  Gray.) 


-Displacement  of  the  fragments  in  Pott's 
fracture.      (After  Gray.) 


Treatment. — In  most  cases  of  fracture  of  one  or  both  bones  of  the  leg  it  is  the 
best  practice  tinder  ansesthesia  to  reduce  the  displacement  by  extension  and  counter- 
extension,  and  apply  the  plaster-of-Paris  dressing  at  once. 

This  should  extend  at  least  half-way  up  the  thigh,  in  all  cases,  in  order  to  fix 
the  knee-joint.  It  is  applicable  to  all  fractures  of  one  ox  both  iDones,  from  the 
knee  down  to  and  including  the  malleoli.     Extension  can  usually  be  made  from 


Fig.   231. — Plaster-of-Paris  dressing  in  fracture  of  leg 


the  heel  and  ankle  by  an  assistant.    A  layer  of  cotton  batting  is  placed  next  to  the 
skin,  a  dry  muslin  or   flannel  roller,  making  firm  compression,  is  applied,   and 


180 


THE  SURGICAL  DISEASES  AND  SURGERY  OF  THE  BONES 


the  plaster  bandages  over  this  (Fig.  231).  The  plaster  cast  should  be  split  down  the 
middle  line^  in  front,  to  guard  against  even  the  remote  danger  of  swelling.  At 
the  end  of  six  or  eight  weeks  all  splints  should  be  removed,  passive  motion  made  at 
the  knee  and  ankle,  and  the  apparatus  reapplied  and  worn  for  at  least  two  weeks 
more. 

In  applying  the  plaster  in  Pott's  fracture  the  eversion  needs  to  be  overcome 
and  the  straight  position  maintained  while  the  gypsum  is  hardening.  Where  the 
deformity  is  extreme  the  foot  should  be  held  in  a  position 
of  slisfht  overcorrection  until  the  cast  hardens. 


Fig.  232. — Petit's  fracture  box.      (After  Stimson.) 

When  plaster-of-Paris  cannot  be  had,  starch  is  next  in  order,  or  splints  of  felt, 
leather,  bookbinders'  board,  metal,  or  wood  may  be  employed.  When  swelling  has 
occurred  the  fracture  box  (Fig.  232)  is  a  most  useful  apparatus.  This  may  be 
placed  ujjon  a  pillow  or  box  to  give  it  a  slight  elevation,  since  the  position  of  partial 
flexion  is  usually  more  comfortable. 


Fig.  233. — Fenestrated  plaster-of-Paris  dressing  for  fixation  and  through-drainage  in  infected  compound 
fractures.  Tin  or  metal  strips  should  be  inserted  on  either  side  of  the  limb  opposite  the  windows 
to  strengthen  the  weak  points  in  the  dressing. 

If  extension  is  needed  it  may  be  secured  by  a  bandage  around  the  ankle  and 
foot,  which  is  also  passed  through  the  holes  in  the  foot  piece.     In  fixing  the  leg 


THE  SURGICAL  DISEASES  AND  SURGERY  OF  THE  BONES 


ISl 


in  this  fracture  box  the  sides  are  turned  down,  a  thick  layer  of  cotton  or  some  soft 
material  arranged  for  the  leg  to  rest  upon,  and  shaped  to  fit  the  natural  contour 
of  the  calf.  The  sides  are  also  packed,  turned  into  position,  and  fastened.  As  soon 
as  the  first  swelling  subsides,  or  as  soon  as  it  is  evident  that  no  marked  swelling 
will  occur,  the  plaster-of-Paris  should  be  apijlied. 

In  fractures  of  the  tibia  near  the  knee  when  an  anssthetic  is  not  administered 
and  muscular  resistance  is  strong,  flexion  of  the  leg  on  the  thigh  and  mechanical 
extension  and  counter-extension  as  shown  in  Fig.  234,  will  accomplish  much  in  the 


Fig.  234. — Mechanical  extension  and  counter-extension  (in  flexion)  by  Downey's  apparatus. 


effort  at  reduction.  The  gyj^sum  dressing  should  extend  from  the  ankle  and  foot 
•to  the  crotch. 

Foot. — The  bones  of  the  tarsus  may  be  broken  by  direct  or  indirect  violence. 

The  diagnosis  is  not  always  easily  made  unless  the  X-ray  is  employed.  The 
best  method  of  treatment  is  fixation  with  a  plaster-of-Paris  dressing.  When  the 
OS  calcis  is  broken,  and  the  tuberosity  drawn  up  by  the  sural  muscles,  the  leg 
sliould  be  flexed  well  upon  the  thigh,  and  the  tarsus  extended  in  order  to  relax 
this  group  of  muscles,  or  the  tendo  Achillis  divided. 

Fracture  of  the  astragalus  is  rare,  and  is  at  times  difficult  of  reposition.  Should 
the  condition  as  revealed  by  the  Eoentgen  ray  demand  a  radical  procedure,  an 
open  operation  may  be  done. 

Fracture  of  the  metatarsal  bones  and  phalanges  should  be  treated  in  the  same 
manner  as  the  corresponding  bones  of  the  upper  extremity. 

Ununited  Fractures — Fibrous  Union. — In  a  certain  proportion  of  cases  union 
between  the  ends  of  broken  bones  is  delayed  beyond  the  time  usually  required  for 
ossification,  and  may  remain  permanently  ununited. 

The  causes  of  ununited  fracture  are:  (1)  Failure  to  secure  immobility;  (2) 
presence  of  muscle,  tendon,  nerve,  or  other  substance  between  the  fragments;  (3) 
violent  and  prolonged  inflammation  of  the  broken  bones  and  the  surrounding  soft 
parts  in  which  granular  degeneration  occurs  with  considerable  loss  of  bone  sub- 
stance; (-1)  any  intercttrrent  disease  which  interferes  with  ntitrition;  (5)  a  too 
great  separation  of  the  fragments.  If  the  ends  of  broken  bones  are  not  kept  in 
contact,  and  at  the  same  time  immovable,  fibrous  union  may  result,  for  by  motion 
the  provisional  callus  is  injured,  and  may  disappear  by  absorption  as  a  result  of 
continued  irritation.  If  the  fragments  overlap,  so  that  no  portion  of  the  broken 
surface  of  one  side  is  in  contact  with  that  of  the  opposite  end,  no  matter  how 
well  adapted  the  dressing  may  be,  muscular  contraction  may.  retard  or  pre- 
vent union. 


182  THE   SURGICAL   DISEASES   AND   SURGERY   OF   THE   BONES 

The  intervention  of  any  of  the  soft  tissues,  or  any  foreign  substance,  may  pre- 
vent tlie  formation  of  calhis,  and  lead  to  fibrous  union. 

Ostitis  after  fracture  may  lead  to  destruction  of  the  fragments,  and  of  the  shafts 
of  bone,  to  such  an  extent  that  union  cannot  occur.  Instances  are  on  record  where, 
resulting  from  fracture,  rarefying  ostitis  has  destroyed  the  entire  bone. 

Any  general  condition  of  impaired  nutrition  increases  the  liability  to  fibrous 
union.  Eickets,  osteomalacia,  syphilis,  tuberculosis,  or  any  acute  fel3rile  disease 
supervening  iipon  fracture,  tends  to  interfere  with  or  to  delay  bony  union. 

The  diagnosis  of  fibrous  union  is  determined  from  continued  preternatural  mo- 
bility at  the  seat  of  fracture  after  two  months  have  elapsed.  Crepitus  is  not  to  be 
depended  iipon,  as  the  ends  of  the  fragments  may  be  rounded  off  by  absorption, 
and  covered  over  with  the  inflammatory  new-formed  material,  or  at  times  with 
cartilage. 

Treatment. — Any  constitutional  disease,  especially  syphilis,  or  any  imiDairment 
of  nutrition,  must  be  specially  treated.  In  the  administration  of  tonics,  cod-liver 
oil,  -ivith  the  hypophosphites  of  lime  and  soda,  should  play  an  important  part. 

It  is  of  importance  to  fix  the  broken  part  immovably  by  the  plaster-of-Paris 
or  other  solid  dressing.  This  should  not  be  removed  for  eight  or  ten  weeks,  when 
passive  motion  of  any  articulation  near  the  seat  of  fracture,  and  necessarily  in- 
cluded in  the  dressing,  should  be  made.  After  the  first  movement  of  the  joint 
the  dressing  should  be  reapplied  and  the  passive  motion  repeated  every  second  week. 
Great  care  should  be  preserved  to  prevent  motion  at  the  seat  of  fracture.  If,  after 
the  lapse  of  from  ten  to  fourteen  weeks,  there  are  no  indications  of  union,  a  mild 
inflammation  should  be  induced  in  the  tissues  immediately  about  the  fracture. 
This  may  be  accomijlished  by  forcibly  rubbing, the  ends  of  the  bones  together  (after 
an  anjEsthetic  has  been-  administered),  and  then  investing  the  member  with  a 
g}'psum  dressing.    If  this  does  not  succeed,  more  radical  measures  must  be  adopted. 

The  line  of  non-union  is  exposed  by  a  free  incision  usually  longitudinal  and  at 
a  point  farthest  removed  from  important  blood  vessels  and  nerves.  The  broken  ends 
are  exposed  by  forcible  bending  at  tlie  point  of  fracture,  and  all  new  tissue  scraped 
or  chiseled  from  the  fractured  surfaces.  Should  the  line  of  fracture  be  oblique,  a 
collar  of  heavy  silver  wire  may  be  easily  slipped  over  first  one  end  and  then  the 
other,  the  surfaces  brought  in  coaptation,  and  firmly  held  in  place  by  twisting  the . 
wire,  the  ends  of  which  are  cut  and  turned  toward  the  bone.  This  collar  of  wire 
requires  very  much  less  time  in  its  application  than  drilling  and  wiring,  and  is  far 
superior. 

When,  however,  the  line  of  fracture  is  transverse,  a  drill  hole  at  least  one  eighth 
of  an  inch  in  diameter  and  one  fourth  or  one  half  inch  from  the  brolcen  surface 
sliould  be  rapidly  made,  preferably  with  a  machine  drill,  in  order  to  save  time  and 
labor,  and  one  or  two  threads  of  good-sized  silver  wire  passed  through  and  twisted. 
In  an  emergency  a  shoemaker's  awl  may  be  substituted. 

It  is  not  always  necessary  to  carry  the  drill  hole  entirely  through  the  bone,  the 
wire  being  brought  out  through  the  medullary  canal  and  reinserted  through  tlie 
canal  on  the  opposite  side.  As  a  rule  the  wire  remains  imbedded  and  harmless  in 
the  reunited  bone.  In  all  of  these  operations  for  ununited  fracture,  the  imj^ortance 
of  the  chromicized  catgut  bundle  drain  should  not  he  overlooked.  It  should  be 
inserted  in  such  a  way  that  the  wound  will  be  immediately  emptied  of  blood  or 
serum. 

In  certain  cases  where  absorjDtion  has  occurred  and  the  fragments  are  pointed 
and  narrow,  instead  of  dividing  the  ends  squarely  across  to  secure  a  broad  surface, 
thereby  losing  in  length  of  limb,  it  is  advisable  to  bevel  the  fragments  on  opposing 
surfaces,  and  hold  them  together  by  a  collar  of  silver  wire.  In  ununited  frac- 
tures of  the  tibia,  a  bone  in  which  tliey  not  infrequently  occur,  it  may  in  rare  . 
instances  be  necessary  to  utilize  the  fibula,  in  order  to  secure  a  fimi  union  in  the 
weakened  tibia.  ^ 

•  Illustrative  Case.  F.,  male,  thirty-two  years  of  age,  received  a  compound  fracture  of  the 
tibia  near  the  junction  of  the  lower  and  middle  third,  in  which  non-union  resulted.  Six  months 
later  an  effort  was  made  to  secure  union  by  inserting  an  ivory  pin  in  the  medullary  canal  at  the 
Jine  of  fracture.     This  also  failed,  and  resulted  in  a  further  absorption  of  the  broken  ends  necessitat- 


THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE  BONES 


183 


When  a  fracture  is  complicated  by  the  injury  of  a  nerve,  or  blood  vessel,  or  when 
the  muscles  are  severely  torn,  it  frequently  becomes  necessary,  even  if  the  wound 
be  not  open,  to  convert  it  into  a  compound  fracture  in  order  to  reunite  a  divided 
nerve,  or  to  tie  or  close  by  suture  the  wound  in  an  artery  or  vein.  The  suture  of 
muscle  is  not  so  important,  although  a  divided  muscle  or  tendon  in  general  requires 
suture.  ISTerve  trunks,  when  not  disturbed  at  the  time  of  fracture,  are  occasionally 
pressed  upon,  and  their  function  partially  or  completely  lost  from  the  pressure  of 
callus,  new  bone,  or  cicatricial  tissue. 

Upon  the  first  sjTnptoms  of  paralysis,  operative  intervention  is  imperative,  with 
or  without  comjilete  division  of  the  injured  nerve  as  the  conditions  may  require, 
and  end-to-end  suture,  as  directed  in  the  chapter  on  the  Surgery  of  the  Nervous 
System. 

A  compound  fracture  is  always  a  grave  injury,  and  the  danger  of  complication 
is  increased  when  a  joint  is  laid  open,  and  is  exposed  to  infection.  In  general  the 
treatment  of  a  compound  fracture  requires  the  most  careful  antisepsis,  and  the 
reduction  of  the  fragments  to  as  near  the  normal  position  as  possible.  In  order 
to  accomplish  this  it  is  often  necessary  to  remove  jwrtions  of  projecting  bone.  Im- 
mobilization by  a  heavy  plaster-of- Paris  dressing  and  the  institution  of  drainage 
will  meet  the  indications.  This  latter  is  one  of  the  most  important  features  in  the 
treatment  of  compound  fractures.  It  is  not  always  possible  to  asepticize  a  compound 
fracture.  Moreover,  it  is  impossible  to  control  bleeding  from  the  broken  ends, 
and  on  this  account  there  is  always  apt  to  be  more  or  less  blood  or  serum  in  the 
deeper  portions  of  the  wound,  which,  if  allowed  to  remain,  would  serve  as  a  breed- 
ing place  for  septic  organisms.  Drainage  can  only  be  efficient  when  it  leads  down- 
ward from  the  deepest  portion  of  the  wound  area  as  the  patient  lies  in  bed  after 
the  operation.  After  cleansing  and  reposition  have  been  effected  a  dressing  forceps 
should  be  pushed  through  from  the  deepest  portion  of  the  wound  to  the  skin 
below,  which  latter  is  incised  and  the  point  of  the  forceps  projected  through  the 
opening.  By  separating  the  jaws  a  drainage  tract  is  established,  and  through  this 
either  a  drainage-tube  or,  preferably,  when  long-continued  drainage  may  not  be 
required,  a  bundle  drain  of  chromicized  catgut  is 
inserted.  This  latter  drain  will  usually  suffice.  It 
should  be  abovit  one  fourth  of  an  inch  in  diameter 
and  made  of  twelve  to  twenty-four  threads  of  No.  3 
chromicized  catgut  parallel  with  each  other,  form- 
ing a  loose  bundle  (not  twisted).  The  ends  should 
be  cut  one -fourth  inch  from  the  level  of  the  skin, 
and  a  sterile  gauze  dressing  ai:)plied.  While  the 
extension  and  counter-extension  (which  has  at  no 
time  been  relaxed)  is  still  made,  the  plaster-of- 
Paris  dressing  is  applied.^     Windows  may  be  cut 

ing  the  following  operation:  Through  a  free  incision,  the  op- 
posing surfaces  of  an  ununited  and  somewhat  obhque  frac- 
ture were  freshened  by  scraping  with  Volkmann's  sharp 
spoon.  The  surface  of  the  tiljia  nearest  the  fibula  was  also 
thoroughly  scraped  and  the  contiguous  surface  of  the  fibula 
treated  in  the  same  way.  This  latter  bone  was  then  broken 
and  firmly  fastened  to  the  tibia  by  the  author's  drills,  which 
after  four  weeks  were  removed.  Union  of  the  fibula  to  the 
tibia  and  of  the  tibial  fragments  to  each  other  resulted  with 
a  restoration  of  function,  as  shown  in  Fig.  235.  This  patient 
now,  after  several  years,  has  perfect  use  of  his  limb. 

'  Illustrative  Case.  Mrs.  M.,  about  forty  years  of  age,  in 
good  physical  condition,  received  an  injury  which  resulted  in 
fracture  of  the  fibula  at  the  external  malleolus,  the  bone  pro- 
jecting an  inch  through  the  torn  integument,  complicated  by 
a  dislocation  at  the  tibio-tarsal  joint,  the  bone  and  the  ankle- 
joint  being  exposed  to  infection.  Under  ether  narcosis,  the 
bone,  joint  and  soft  tissues  were  thoroughly  cleansed  with 
1-1000  mercuric  chloride  solution,  a  number  of  pieces  of 
broken  bone  removed  with  the  rongeur,  the  dislocated  bone  y^^  235.— Union  of  the  fibula  with 
ana  jomt  reduced.     A  crescent-shaped  frmge  of  bone  which  the  tibia  to  strengthen  a  weak 

had  beea  torn  away  with  the  external  lateral  ligament  was  spot  in  the  latter.     (Case  of  F.) 


184  THE   SURGICAL   DISEASES  AND   SURGERY   OF   THE   BONES 

as  sliown  in  Kg.  233.  TJpon  the  first  indication  of  sepsis,  the  dressing  should  be 
changed,  the  wound  carefully  examined,  and  a  more  thorough  drainage  instituted. 

brought  back  to  its  natural  position  and  held  in  place  by  compression.  A  catgut  bundle  drain  was 
inserted  from  the  middle  of  the  ankle-joint  and  carried  downward  through  a  fresh  wound  made  for 
this  purpose.  A  sterile  gauze  dressing  was  applied,  and  over  all  plaster-of-Paris  immobilization, 
the  foot  being  fixed  in  the  position  of  slight  eversion.  This  dressing  was  not  removed  for  four 
weeks,  when  the  wound  was  found  entirely  healed.  No  infection  had  occurred  and  the  catgut 
drain  had  disappeared.  Later  a  prothetic  apparatus  was  adjusted  to  support  the  weakened 
ankle  as  the  patient  walked. 


CHAPTER    X 

THE    JOINTS DISLOCATIONS 

Dislocations  are  traumatic,  pathologkal,  and  congcnUal.  They  may  be  par- 
tial or  conij^lete.  and  are  described  as  sinijjle,  eomjjlicated,  and  componnd. 

Traumatic  dislocations  may  occur  from  a  blow  or  fall  directly  upon  the  joint, 
or  by  force  transmitted  along  one  or  more  bones  forming  the  articulation.  Patho- 
logical dislocations  are  caused  chiefly  by  tubercular  osteo-arthritis,  with  pyogenic 
infection,  which  results  in  a  more  or  less  extensive  destruction  of  the  cartilages 
and  bones  entering  into  the  Joint,  together  with  rupture  of  the  capsule  through 
which  the  disarticulation  takes  place.  A  congenital  dislocation  is  due  to  a  failure 
of  development  in  the  Joint  structures,  in  which  the  normal  contiguity  of  the  articu- 
lar surfaces  cannot  be  maintained.  A  dislocation  is  said  to  be  partial  when  any 
portion  of  the  articular  surfaces  are  still  in  contact;  complete  when  one  articular 
surface  overlaps  the  other;  simple  when  there  is  no  other  lesion  than  displacement 
and  injury  of  the  capsule;  complicated  when  there  exists  with  the  dislocation  a 
fracture  into  the  Joint;  compound  when,  by  reason  of  a  wound,  the  air  is  in  con- 
tact with  the  dislocated  surfaces.  Again,  a  dislocation  may  be  recent  or  ancient, 
the  limit  of  the  former  variety  being  from  a  few  hours  to  two  or  three  weeks.  A 
primitive  luxation  is  one  in  which  the  dislocated  surfaces  retain  the  same  position 
as  at  the  time  of  the  accident,  secondary  when  another  position  is  assumed. 

In  dislocation  the  capsule  is  almost  always  ruptured,  but  occasionally,  on  ac- 
coimt  of  extreme  relaxation  of  the  ligaments,  the  articular  surfaces  may  J3e  widely 
separated  and  become  displaced  from  their  normal  relations  without  capsular  rup- 
ture. In  addition  to  rupture  of  the  capsule,  the  violence  which  produces  the  dis- 
location is  at  times  so  great  that  muscles,  tendons,  nerves,  vessels,  and  at  times 
the  fascia  and  skin  about  the  joint  may  be  torn  or  perforated. 

Dislocations  occur  chiefly  in  adult  life,  and  are  more  frequent  in  those  joints 
which  enjoy  normally  the  greatest  freedom  of  motion,  and  at  the  same  time  are 
subject  to  heavy  strains.  Patients  with  poorly  develo]xvl  muscles  and  relaxed 
ligaments  are  more  prone  to  these  lesions  than  the  well-(lc\i'li>])cil  and  vigorous. 

The  diagnosis  of  dislocations  rests  chiefly  upon  abnoriiinl  iiuiiiiiliility  and  asym- 
metry. Pain  and  swelling  are  usually  present.  The  Roentgen  ray  is  indispensable 
to  an  alisolutely  correct  jjicture  of  the  injured  articulation. 

Special  Dislocations — Inferior  Maxilla. — Displacement  of  the  condyles  of  the 
lower  jaw,  from  its  ai'ticulation  with  the  temporal  bone,  may  occur  on  one  or  both 
sides;  usually  it  is  bilateral.  The  condyles  slip  forward  and  are  engaged  partly 
beneath  the  zygoma,  in  front  of  the  emincntia  articularis,^  and  partly  between  the 
z3-goma  and  the  temporal  fossa.  Muscular  action  alone  may  produce  this  luxation, 
or  it  may  be  caused  by  external  violence. 

The  symptoms  are  great  pain,  difficult  deglutition,  and  indistinct  articulation 
(especially  of  the  labial  sounds).  The  lower  teeth  are  unusually  advanced,  the 
mouth  is  opened,  and  the  saliva  trickles  over  the  lips. 

In  unilateral  luxation  the  chin  points  toward  the  sound  side,  and  the  teeth 
are  less  widely  separated. 

In  the  diagnosis  the  chief  point  of  differentiation  is  fracture  at  or  near  the 
cond3'le.  In  fracture  the  condyle  may  possibly  be  recognized  in  its  normal  position 
by  palpation;  immobility  is  not  marked;  the  mouth  is  not  opened;  crepitus  may 
be  obtained, 

185 


186  THE   JOINTS— DISLOCATIONS 

Reduction. — In  bilateral  displacement,  wrap  the  thumbs  with  several  layers  of 
bandage  or  cloth,  to  protect  them  from  being  bitten  when  reduction  is  accomplished. 
Place  one  thumb  along  the  inferior  molars  of  each  side,  and  the  fingers  beneath 
the  body  of  the  jaw;  press  downward  and  backward  with  the  thumbs,  while  the 
fingers  lift  the  chin  upward. 

Or  place  a  thick  roll  of  leather,  piece  of  wood,  or  firm  cork,  between  the 
upper  and  lower  posterior  molars  of  each  side,  and  upon  these,  as  a  fulcrum, 
lift  the  chin  upward,  and  at  the  same  time  push  backward  in  the  direction  of 
the  socket. 

If  both  of  these  methods  fail,  they  should  be  repeated  under  ansesthesia.  It 
may  sometimes  be  advisable  to  attempt  the  reduction  of  one  side  by  either  of  the 
above  methods,  and  retain  it  in  position  while  reducing  the  other. 

After  reduction  is  completed  put  on  a  head  and  chin  figure-of-8  bandage,  and 
allow  it  to  remain  for  a  week  (Fig.  53),  or  apply  Hamilton's  head-stall  for  fracture 
of  the  lower  jaw  (Fig.  192).  In  several  instances,  where  the  dislocation  has  be- 
come permanent,  the  symptoms  have  gradually  suljsided,  and  a  fair  degree  of 
motion  and  usefulness  acquired  through  the  false  joint. 

Clavicle. — The  sternal  end  may  be  displaced  forward  on  the  manubrium,  up- 
ward above  the  sternum,  backward  behind  the  manubrium.  The  last  two  varieties 
are  rare.  The  cause  of  the  first  form  is  usually  force  applied  to  the  shoulder  with 
the  arm  thrown  backward.  In-  the  case  of  a  boy  fifteen  years  old,  treated  by  myself, 
the  displacement  was  caused  by  a  comrade  catching  him  by  both  shoulders,  placing 
his  laiee  in  the  middle  of  the  back,  between  the  shoulder-blades,  and  violently 
pulling  the  shoulders  l^ack. 

The  diagnosis  is  not  diflicult,  the  reduction  easy,  but  the  maintenance  of  the 
bone  in  position  difficult.  A  compress,  covered  with  adhesive  plaster  to  prevent 
slipping,  placed  upon  the  bone  after  reduction,  and  fi.rmly  held  in  place  by  a  roller, 
is  a  proper  method  of  treatment.  The  arm  should  be  fixed  with  Sayre's  apparatus 
for  fractured  clavicle,  in  order  to  prevent  a  repetition  of  the  luxation. 

The  outer  end  of  the  clavicle  may  be  displaced  above  or  below  the  acromion 
process,  and  above  or  in  front  of  the  coracoid  process.  Displacements  under  the 
acromion  and  in  front  of  the  coracoid  are  very  rare. 

The  symptoms  are  very  distinct,  and  the  reduction  not  surrounded  with  great 
difficulty.  When  replaced,  however,  the  bone  is  not  easily  maintained  in  posi- 
tion. By  drawing  firmly  outward  upon  the  shoulder  of  the  affected  side,  and  press- 
ing the  clavicle  downward  into  position,  reduction  will  be  successfully  accomplished. 
Place  a  firm  compress  over  the  end  of  the  bone,  bend  the  forearm  at  right  angles 
to  the  arm,  and  carry  one  or  two  strong  strips  of  adhesive  plaster  over  the  com- 
press, behind  the  shoulder,  along  the  amr  to  the  olecranon,  and  again  by  the  front 
over  the  comjjress.  Eeiinforce  this  by  a  bandage,  and  place  the  arm  in  a  sling. 
If  luxation  recurs,  tighten  the  adhesive  strips,  and  place  the  arm  in  a  Velpeau's 
bandage.  To  apply  this  bandage,  place  the  hand  of  the  affected  side  almost  upon 
the  opposite  shoulder,  fixing  a  wad  of  cotton  beneath  each  axilla.  Lay  the  end 
of  a  roller  on  the  shoulder-blade  of  the  sound  side,  and  carry  the  bandage  over 
the  acromial  end  of  the  clavicle  of  the  injured  side,  and  the  front  of  the  arm  for 
a  short  distance,  piassing  obliquely  to  the  under  surface  at  the  elbow,  and  around 
beneath  the  well  axilla  to  the  point  of  starting.  Eepeat  this  to  secure  the  roller, 
and  then  carry  the  bandage  horizontally  around  the  chest  and  over  the  tip  of  the 
elbow.  The  oblique  and  horizontal  turns  are  alternated  until  the  shoulder  and 
arm  are  comjjletely  enveloped  (Fig.  197). 

Shoulder-joint. — Dislocation  at  this  joint  may  take  place  in  any  direction,  but 
in  the  vast  majority  of  instances  the  head  of  the  bone  is  carried  through  the 
inner  aspect  of  the  capside  and  is  lodged  in  the  axilla  beneath  the  coracoid  process, 
or  is  pushed  farther  inward,  lying  beneath  the  clavicle;  it  occasionally  rests  at 
the  mai'gin  of  the  glenoid  fossa. 

These  three  varieties  are  laiown  as  the  siibglenoid,  suhcoracoid,  and  suh- 
clavicular. 

Occasionally  the  dislocation  is  backward  {suhspinous) ,  the  head  of  the  bone 
resting  beneath  the  base  of  the  acromion  process  or  the  spine  of  the  scapula.     In 


THE   JOINTS— DISLOCATIONS 


187 


very  rare  instances  the  bone  may  be  displaced  directly  upward,  carrying  the  acro- 
mion process  with  it. 

In  suhcoracoid  dislocation  a  diagnosis  may  be  made  by  a  earefol  comparison 
of  the  injured  with  the  uninjured  side.  It  will  be  observed  that  while  the  arm 
of  the  uninjured  side  in  relaxation  falls  directly  downward,  the  humerus  parallel 
with  and  practically  in  contact  with  the  chest  wall,  on  the  opposite  side  the 
humerus  is  tilted  outward  so  that  the  elbow  of  the  dislocated  side  is  several  inches 
farther  from  the  surface  of  the  body  than  upon  the  normal  side.  Efforts  at  motion 
will  reveal  stiffness  or  marked  immobility  on  the  affected  side.  Firm  pressure 
with  the  end  of  two  fingers  directly  under  the  acromion  process  of  this  side  will, 
in  subjects  not  overfleshy  or  of  extraordinary  muscular  development,  demonstrate 
absence  of  the  head  of  the  bone  which  under  ordinary  conditions  may  be  recog- 
nized in  its  abnormal  position  in  the  axilla.  In  doubtful  cases,  comparative  meas- 
urement around  the  shoulder- joint,  over  the  acromion,  and  through  the  axilla  will 
show  the  circumference  from  one  to  two  inches  greater  upon  the  side  of  dislocation 
than  upon  the  normal  side,  even  when  there  has  occurred  no  swelling  (Callaway). 
Moreover,  if  the  hand  of  the  affected  side  is  placed  upon  the  sound  shoulder,  the 
elbow  cannot  be  carried  down  to  the  chest  wall  as  iipon  the  other  side  (Dugas). 

When  the  dislocation  is  posterior  (subspinous) ,  the  head  of  the  bone  may  with- 
out difficulty  be  felt  in  this  abnormal  and  more  superficial  position. 

Treatment  (Kocltcr's  MeiJtod) — Inivard  Dislocations. — In  these  dislocations  it 
has  been  demonstrated  by  Professor  Kocher,  of  Berne,  that  the  obstacles  to  replace- 
ment of  the  head  of  the  bone  could  be  overcome  by  manipulation,  as  follows: 

The  patient,  under  complete  narcosis,  is  placed  upon  the  back  upon  a  hard 
table  or  the  floor,  with  an  assistant  holding  the  shoulder  of  the  sound  side  firmly 
down.  The  operator  grasps  the  member  of  the  injured  side  at  the  wrist  and  elbow 
and  brings  the  humerus  well  against  the  wall  of  the  chest  (Fig.  236).     Outward 


Fig.  236.— First  i\Iuvi_im-nt.      iin;  ulbow  is  addueted  to  tlic  body  aiul  drawn  do\Mi\\aid       (The  arm 
and  wrist  should  be  firmly  grasped,  as  shown  in  the  figure.)      (After  Dr.  C.  A.  Poweis  ) 

rotation  is  made  until  the  long  axis  of  the  forearm  points  directly  outward  (Fig. 
337),  when  the  elbow  is  brought  along  the  front  of  the  chest  to  the  median  line 
(Fig.  238)  and  the  humerus  rotated  inward  until  the  hand  of  the  affected  side  is 
placed  on  the  sound  shoulder  (Fig.  239).  If  this  fail,  repeat  the  procedure.^  It  is 
always  advisable  to  operate  with  the  patient  fully  relaxed  by  an  ansesthetic.  In 
exceptional  cases  it  mav  be  successfully  reduced  without  narcosis.  Should  this 
method  fail,  that  of  using  the  foot  in  the  axilla,  as  given  for  subglenoid  luxation, 
may  also  be  tried, 


Fig.  237. — Second  Movement.     The  arm  is  rotated  out  until  firm  resistance  is  met.      (Practically  until 
the  long  axis  of  the  forearm  points  directly  outward.)      (After  Dr.  C.  A.  Powers.) 


Fig.  23S.— Third  W.)\.  lin  111       Wiiliili.i     i.iiiiln,!    tin     111        ii         ill  i     iii  I  i  lu  d,  tliL  elbow  is  car- 
ried ioru  aid  and  upwjicl  uu  lla  chc^l       (.  iltLi  JJi    L     V    loi\cib) 


.fill  mil  liHi; 

Fig.  239, — Fourth  Movement      The  hand  is  placed  on  the  sound  shoulder.     (After  Dr.  C.  A.  Powers.) 


THE   JOIXTS— DISLOCATIOXS 


189 


The  siibcJavicidar  variety  of  this  forward  dislocation  is  an  exaggeration  of  the 
subcoracoid,  in  which  the  head  of  the  bone  slips  underneath  and  internal  to  the 
coraeoid,  and  rests  agaiast  the  serratns  magnus  and  behind  the  pectoralis  minor, 
below  the  clavicle  (Fig.  242).  The  causes  are  the  same,  and  the  sjTnptoms  differ 
in  little  else  than  the  presence  of  the  head  of  the  humerus  nearer  to  the  clavicle. 
The  arm  stands  out  from  the  body,  and  the  elbow  is  tilted  baclrward.  The  tension 
on  the  posterior  scapular  muscles  is  greater,  and  rupture  of  their  attaclunents  often 
occurs,  while  the  anterior  insertion  of  the  subscapularis  maj^  be  torn.  Pressure 
on  the  axillary  vessels  and  nerves  is  more  marked  ia  this  luxation.  Eeduction  may 
be  effected  by  the  means  just  described. 


Fig.  240. 

Fig.  241. 

Fig.  242. 

Fig.  243. 

Subacromial  and  sub- 

Subfflenoid. 

Subcoracoid. 

Subcla^cular. 

spinous.      (Brj'ant.) 

(Br>-ant.) 

(Brj-ant.) 

(Brj-ant.) 

Siibglenoid  Dislocation. — In  the  subglenoid  luxation  tlie  capsule  is  stretched 
or  torn  along  its  lower  surface,  and  the  head  of  the  humerus  rests  on  the  margin 
of  the  glenoid  cavity,  or,  if  the  rent  in  the  capsule  is  suiBciently  extensive,  it  may 
slip  in  front  of  the  long  tendon  of  tlie  triceps,  and  be  lodged  upon  the  axillary 
border  of  the  scapula,  immediately  below  the  articadar  surface  (Fig.  "241).  The 
supraspinatus  muscle  is  severely  stretched,  and  either  suffere  rupture  of  its  tendon 
or  substance,  or  it  may  tear  off  a  rim  of  the  upper  facet  of  the  greater  tuberosity. 
The  long  head  of  the  biceps  and  the  coraco-brachialis  are  also  subjected  to  great 
strain  or  possible  rupture,  while  the  tension  of  the  deltoid  holds  the  ami  in  a  posi- 
tion with  the  elbow  slightly  tilted  from'  the  side  of  the  body. 


Fig.  244. — (Eriehsen.) 

Among  the  less  frequent  complications  of  this  lesion  may  be  mentioned  pressure 
upon  the  circumflex  and  axillary  nerves,  and  injury  or  rupture  of  the  great  vessels. 


190  THE  JOINTS— DISLOCATIONS 

Should  Koclier's  method  fail,  jolace  the  patient  upon  a  table,  bed,  or  upon  the 
floor.  For  the  left  shoulder  the  operator  removes  the  shoe  from  the  left  foot 
and  places  it  in  the  axilla,  against  the  thorax.  He  now  seizes  the  arm  and  forearm 
of  the  patient,  carries  it  out  at  a  right  angle  to  the  axis  of  the  patient's  spine, 
and  makes  j^owerful  traction  in  the  direction  of  the  glenoid  cavity.  While  this  is 
being  effected  the  arm  is  brought  inward,  parallel  with  and  against  the  side  of  the 
body  (Fig.  244).  The  foot  not  only  serves  to  effect  counter-extension,  but  is  also 
used  as  a  fulcrum  for  lifting  the  head  of  the  bone  over  the  edge  of  the  glenoid 
facet  into  the  articular  cavity  of  this  firocess.  After  reduction  a  shoulder-cap  of 
bookbinders'  board,  leather,  or  gutta-percha  should  be  ajDplied,  and  worn  for  at 
least  one  week. 

The  s^ibacromial  and  subspinous  dislocations  are  reducible  by  extension  and 
counter-extension  in  the  line  of  displacement.  Counter-extension  may  be  made 
by  an  assistant  holding  the  arm  of  the  sound  side,  or  by  the  folded  sheet  (already 
described)  applied  just  in  the  axilla.  The  operator  makes  extension  from  the  arm 
and  forearm,  imparting  to  the  humerus  a  slight  axial  rotation. 

General  Considerations. — Even  with  an  experienced  operator  and  the  proper 
emplojTnent  of  anaesthesia,  occasionally  a  dislocation  at  the  shoulder  is  found  im- 
possible of  reduction  without  an  operation  which  exposes  the  joint.  Under  such 
conditions  and  under  strict  asepsis,  this  is  imperative  when  all  else  fails.  The 
incision  should  be  in  the  general  axis  of  the  arm  along  the  anterior  inner  aspect, 
sacrificing  as  few  of  the  fibers  of  the  deltoid  as  possible.  Hffimorrhage  should  be 
controlled  as  the  operation  proceeds,  so  that  important  structures  may  be  recognized 
and  avoided.  When  reduction  is  effected  the  wound  should  be  closed  with  catgut 
wis]^  drain  in  the  lower. angle. 

The  danger  of  injury  to  the  nerves  and  vessels  of  the  axillary  region  in  the 
efforts  at  reduction  should  always  be  carefully  considered. 

In  all  cases  the  difliculties  increase  when  reduction  is  delayed.  The  formation 
of  adhesions,  muscular  shortening,  and  the  contraction  of  the  rent  in  the  capsule 
add  ever-increasing  obstacles  to  reposition.  If  operation  has  been  delayed  longer 
than  forty-eight  hours,  these  dangers  should  be  carefully  stated  in  the  prognosis. 
Eeduction  after  two  or  three  weeks  will  fail  in  the  majority  of  instances,  and  after 
six  weeks  it  is  almost  impossible  of  accomplishment. 

In  cases  jsroperly  selected,  where  an  ancient  dislocation  exists,  and  where  motion 
is  so  restricted  that  the  usefulness  of  the  arm  is  seriously  impaired,  the  0]5en  opera- 
tion may  be  advised.  Failing  in  all  efforts  at  reposition  after  the  head  of  the  bone 
is  exposed,  the  propriety  of  excision  may  be  considered  not  only  to  relieve  pressure 
upon  the  nerves  and  vessels  of  the  axilla,  but  in  the  hope  of  increasing  motion. 

Wren  the  dislocation  is  complicated  with  fracture  of  the  surgical  neclc,  Mc- 
Burney's  operation  as  given  in  connection  with  fractures  of  this  bone  should  be 
performed.  When  the  presence  of  the  head  of  the  bone  in  the  axilla  does  not 
cause  pain  or  paralysis  %  pressure  upon  the  nerves,  and  does  not  interfere  with 
the  circulation  in  the  arm,  it  has  been  demonstrated  that  surgical  fracture  at  the 
neck  of  the  humerus  followed  by  regular  and  long-continued  passive  motion,  will 
develop  a  false  joint  at  the  point  of  fracture  and  restore  in  great  measure  the 
movements  of  the  arm. 

Passive  motion  should  be  made  once  or  twice  each  week,  or  less  frequently 
should  any  considerable  degree  of  inflammation  or  soreness  be  developed. 

The  employment  of  nitrous-oxide  gas  anesthesia  is  invaluable  in  the  treatment 
of  these  cases.  Its  administration  is  so  simple  and  safe,  and  as  the  effects  pass 
off  immediately  patients  will  not  hesitate  to  present  themselves  for  treatment, 
which  is  rarely  the  case  when  ether  or  chloroform  are  repeatedly  employed. 

Dislocations  at  the  Elboiv-joint. — The  upper  end  of  the  radius  may  be  displaced 
forward  on  to  the  anterior  surface  of  the  humerus,  near  the  coronoid  fossa,  or 
baclcward  upon  the  olecranon  process.  The  anterior  displacement  is  met  with 
somewhat  more  frequently  than  the  posterior. 

In  the  displacement  forward  the  orbicular  and  a  portion  of  the  external  lateral 
and  anterior  ligaments  are  ruptured ;  in  the  opposite  luxation  only  the  first  two  are 
lacerated. 


THE   JOINTS— DISLOCATIONS  191 

The  forward  clisjDlacement.  is  caused  by  direct  violence  applied  to  the  posterior 
aspect  of  tlie  vipper  end  of  the  radius,  or  by  falling  upon  the  palm  of  the  hand, 
the  full  force  of  the  contraction  of  the  biceps  being  thus  added  to  the  force  trans- 
mitted along  the  shaft  of  the  bone. 

Diagnosis. — Careful  palpation  will  reveal  the  abnormal  presence  of  the  head 
of  the  radius  near  the  center  of  the  humerus,  while  pressure  along  the  outer  con- 
dyle will  demonstrate  its  absence  from  its  natural  position.  The  forearm  is  semi- 
flexed and  slightly  pronated.  The  fluoroscope  will  reveal  the  exact  nature  of  the 
displacement,  and  should  be  utilized  to  demonstrate  the  success  of  the  reduction. 

Treatment. — Flex  the  arm  and  push  the  head  of  the  bone  forcibly  downward 
in  the  direction  of  the  articulation.  When  reduction  is  accomplished,  place  a  com- 
press over  the  upper  end  of  the  bone  and  tlie  external  condyle,  and  bind  it  firmly 
in  position.  The  arm  sliould  be  snugly  bandaged,  and  carried  in  a  sling  for  several 
weeks. 

The  bad- ward  dislocation  is  recognized  by  tlie  presence  of  the  head  of  the  bone 
in  an  abnormal  position  near  the  olecranon,  behind  the  external  condyle. 

Treatment. — While  an  assistant  makes  strong  extension  and  counter-extension 
from  the  hand  and  arm,  the  operator  makes  direct  pressure  upon  the  head  of  the 
bone,  forcing  it  in  the  direction  of  the  articulation.  As  the  displacement  is  being 
corrected  the  assistant  should  carry  the  forearm  in  a  position  of  supination.  The 
after-treatment  consists  of  a  compress  and  bandage,  worn  for  several  weeks. 

The  prognosis  of  this  injury  is  generally  not  favorable,  since  it  is  very  apt  to 
recur  after  reduction,  and  may  become  permanent.  A  fair  degree  of  usefulness 
is  maintained,  however,  in  many  cases  of  chronic  luxation  of  this  end  of  the  radius. 
The  production  of  a  rich  callus,  more  or  less  permanent,  resulting  ■  from  raising 
the  periosteum  as  the  ligaments  are  torn  is  a  frequent  cause  of  impaired  motion 
after  this  injury. 

Complete  forward  dislocation  of  the  ulna  alone,  at  the  elbow,  cannot  occur 
without  fracture  of  the  radius  or  extensive  laceration  of  the  radio-ulnar  ligaments. 

Suhluxation  of  the  Head  of  the  Radius. — This  lesion  is  met  with  usually  in 
children  from  nine  years  old  and  under,  and  is  much  more  common  than  complete 
dislocation  at  this  joint.  It  is  caused  by  sudden  traction  on  the  hand  or  forearm 
in  lifting  a  child  by  a  single  arm  or  in  saving  it  in  the  act  of  falling. 

The  sym])toms  are  loss  of  function,  the  arm  often  hanging  as  if  it  could  not 
be  moved.  Motion  at  the  -nTist,  however,  may  be  free.  Pressure  over  the  liead  of 
the  radius  causes  sharp  pain.  Passive  flexion  at  the  elbow  is  permitted  to  about 
sixty  degrees,  when  resistance  may  be  met  with.  Complete  extension  is  also  painful. 
With  the  forearm  flexed  at  a  right  angle  to  the  arm,  pronation  is  possible,  but  is 
slightly  resisted,  while  supination  causes  great  pain.  If,  however,  this  movement 
is  carried  to  the  extreme,  a  distinct  click  may  be  heard  and  felt  at  the  head  of 
the  radius,  with  which  the  pain  suddenly  ceases  and  free  motion  is  reestablished 
(W.  W.  Van  Arsdale).! 

Reduction. — With  the  patient  sitting  or  standing  in  front  of  the  operator,  he 
grasps  the  arm  just  above  the  elbow  with  one  hand,  while  with  the  other  the  fore- 
arm is  seized  near  the  wrist.  The  forearm  is  now  flexed  to  an  angle  of  ninety 
degrees  with  the  arm,  and  steadily  rotated  into  a  position  of  extreme  supination. 
As  above  stated,  the  reduction  is  accompanied  by  a  perceptible  slip  or  click.  A 
splint  should  be  ajjplied  to  hold  the  arm  quiet  in  the  right-angle  position  for  four 
or  five  days. 

Dislocation  of  both  radius  and  ulna  at  the  elbow  may  take  place  in  all  directions. 

The  dislocation  backward  may  be  produced  by  falling  upon  the  hand  with 
the  forearm  almost  extended;  by  a  blow  upon  the  anterior  aspect  of  the  forearm, 
near  the  elbow,  a  blow  upon  the  posterior  surface  of  the  humerus,  in  its  lower 
portion,  or  force  applied  at  the  same  time,  in  opposite  directions,  upon  these  sur- 
faces. The  coronoid  process  will  be  found  lodged  in  the  olecranon  fossa,  the  upper 
end  of  the  radius  resting  on  the  posterior  aspect  of  the  external  condyle. 

The  anterior  ligament  and  the  anterior  fasciculi  of  the  external  and  internal 

i  "Annals  of  Surgery,"  June,  1889. 


192  THE   JOINTS— DISLOCATIONS 

lateral  ligaments  are  torn  loose,  and  in  extreme  cases  the  orbicular  ligament  may 
give  way,  although  the  yielding  of  the  external  ligament  usually  saves  the  circular 
ligament  from  being  torn.  The  tendon  of  the  brachialis  anticus  is  stretched  or 
is  broken  loose  from  the  coronoid  process.  Pressure  upon  the  brachial  arteiy  may 
be  so  great  that  jiulsation  at  the  wrist  is  diminished  or  absent,  while  in  extreme 
cases  the  median,  ulnar,  or  musculo-spiral  nerves  may  be  injured. 

The  usual  position  of  the  forearm  is  one  of  almost  complete  extension,  with 
pronation.  Measurement  from  the  inner  -  condyle  to  the  styloid  process  of  the 
ulna  will  demonstrate  shortening.  Muscular  rigidity  is  marked,  and  motion  of 
the  displaced  bones  difficult  and  painful.  From  these  s}anptoms  the  diagnosis  can 
be  readily  made.  If  swelling  has  ensued,  and  the  tumefaction  is  great,  it  is  not 
always  easy  or  possible  to  recognize  the  character  of  the  injury.  It  is  best  under 
such  conditions  to  anasstlietize  the  jiatient,  determine  the  exact  nature  of  the  injury, 
and  treat  it  at  once  rather  than  wait  until  the  swelling  is  reduced. 

Reduciion. — The  j^atient,  fully  anfesthetized,  should  be  placed  upon  the  liack 
on  a  firm  table,  and  a  chair  so  placed  that  the  knee  of  tlie  operator,  pressing  against 
the  lower  anterior  aspect  of  the  humerus  near  the  elbow,  may  be  used  in  counter- 
extension  to  the  force  employed  by  traction  on  the  forearm. 

The  forearm,  flexed  at  an  angle  of  ninety  degi-ees  upon  the  humerus,  is  now 
grasped  near  the  wrist  by  the  operator  and  strong  traction  made,  accompanied  by 
slightly  increasing  flexion.  This  increased  flexion  unlocks  the  coronoid  process 
from  the  olecranon  fossa,  while  extension  carries  both  bones  forward  into  position. 
When  reposition  is  affected,  a  right-angle  splint  should  be  applied  and  worn  for 
a  week  or  ten  days. 

A  cloth  or  sheet  folded  around  the  patient's  arm  just  al)ove  tlie  elbow  may 
also  be  employed  for  cou-nter-extension.  Should  reposition  not  be  effected  in  the 
position  of  flexion,  Liston's  metliod  of  making  extension  from  the  forearm  and 
counter-extension  from  the  shoulder  with  the  arm  and  forearm  held  straight  may 
be  substituted. 

Dislocation  of  the  radius  and  ulna  forward,  without  fracture  of  the  olecranon, 
is  of  rare  occurrence,  and  is  always  the  result  of  great  violence.  Eupture  of  the 
posterior  and  lateral  ligaments  occurs,  and  the  tricejjs  tendon  is  torn  or  greatly 
stretched,  while  the  brachialis  anticus  and  bicejis  are  relaxed.  The  posterior  por- 
tion of  the  olecranon  rests  upon  the  anterior  articular  aspect  of  the  humerus,  or 
may  slip  into  the  coronoid  fossa.  The  forearm  is  bent  at  an  angle  varying  from 
ninety  to  one  hundred  and  twenty  degrees  to  the  anterior  surface  of  the  humerus, 
and  is  well  supinated.  Motion  is  painful  and  limited.  The  character  of  the 
injury  may  be  determined  by  the  absence  of  the  olecranon  projection,  the  smooth, 
broad,  posterior  surface  of  the  lower  end  of  the  humerus  being  readily  appre- 
ciated. 

Reduction. — An  anaesthetic  is  required.  With  the  forearm  held  at  a  right  angle 
to  the  arm,  make  extension  from  the  wrist,  and  counter-extension  from  the  lower 
anterior  surface  of  the  humerus,  in  order  to  disengage  the  olecranon  process  from 
the  coronoid  fossa,  and,  when  this  is  effected,  make  direct  pressure  downward  upon 
the  anterior  aspect  of  the  forearm,  near  the  elbow.  After  the  laones  slip  seemingly 
into  position,  careful  examination  should  be  made  to  see  that  the  radius  is  in  its 
proper  relation  to  the  external  condjde,  for  the  ridge  between  the  two  sigmoid  cavi- 
ties of  the  ulna  may  lodge  in  the  groove  between  the  trochlear  surface  and  the 
articular  surface  for  the  head  of  the  radius. 

In  the  outward  lateral  dislocation  the  luxation  is  iisiaally  partial.  Tlie  cause 
is  direct  violence  applied  to  the  inner  aspect  of  the  forearm,  near  the  joint,  or  to 
the  outer  aspect  of  the  humerus,  low  down,  or  to  force  applied  simultaneously,  in 
opposite  directions,  upon  these  two  surfaces. 

The  diagnosis  will  rest  chiefly  upon  the  increased  prominence  of  the  inner  con- 
dyle, and  the  difiiculty  of  recognizing  the  outer  condyle  by  paljjation.  The  angle 
at  the  elbow  is  about  one  hundred  and  twenty  degrees,  motion  is  wanting,  and  the 
hand  is  pronated.  Eeduction  is  best  effected  by  strong  extension  from  the  forearm, 
counter-extension  from  the  humeras,  and  direct  lateral  pressure  in  the  direction 
of  the  displacement. 


THE  JOINTS— DISLOCATIONS  193 

Inward  dislocation  is  ahvaj's  ineoni2:)lete  (Hamilton).  The  causes  are  direct 
violence  in  the  opposite  direction  to  that  given  for  the  luxation  outward.  The 
internal  eondj'le  will  be  less  prominent,  the  external  more  prominent,  the  olecranon 
will  be  seen  crowded  over  to  the  inner  aspect  of  the  joint,  while  the  head  of  the 
radius  rests  near  the  middle  of  the  articular  surface  of  the  humenis.  The  position 
of  the  forearm  is  that  of  flexion.  Eeduction  is  difficult,  and  should  be  effected  in 
ether  narcosis.  Extension  and  counter-extension  should  be  made  in  the  flexed 
position,  and  the  arm  gradually  brought  out  straight,  while  at  the  same  time 
direct  pressure  is  made,  in  projjer  and  opposite  directions,  upon  the  humerus  and 
forearm,  near  the  joint. 

Dislocation  of  both  bones  backward  is  the  most  frequent  form  of  displacement 
at  the  elbow.  Incomplete  external  and  incomplete  internal  luxation  are  next  in 
order  of  frequenc}*,  while  the  forward  dislocation  is  rare. 

In  tlie  posterior  variety  the  direction  of  the  force  may  be  such  that  a  deviation 
to  one  or  the  other  side  may  occur.  The  treatment  is  practically  the  same.  Direct 
lateral  pressure  in  the  line  of  the  normal  position  of  the  bone  may  be  required 
in  addition  to  the  mechanism  of  reduction  above  given.  Partial  ankylosis  is  not 
infrequent  after  these  lesions.  Passive  motion  should  be  begun  within  two  weeks 
after  the  injury,  and  repeated  daily  if  no  acute  inflammation  is  produced. 

Wrist-joint. — Dislocations  at  the  carpo-radial  joint  are  very  rare.  Only  a  few 
instances  of  complete  bacl'irard  or  forward  luxation  of  the  carpus  are  on  record. 
Lateral  dislocations  are  considered  impossible  without  fracture  of  the  styloid  process 
of  the  radius  or  ulna.  The  two  principal  displacements  occur  with  about  equal 
frequency.  In  the  bacl-ivard  variety  the  anterior  aspect  of  the  carpus  rests  upon 
the  dorsal  rim  of  the  cancellous  expansion  of  tlie  radius,  the  reverse  being  true  in 
the  dislocation  forward.  The  anterior  and  posterior  ligaments  are  partially  or 
completely  ruptured,  and  the  annular  ligament,  which  binds  the  tendons  down, 
may  be  torn  and  the  tendons  displaced. 

The  cause  of  the  backward  displacement  is  a  fall  on  the  back  of  the  hand,  or 
a  blow  upon  the  dorsum  of  the  radius,  just  above  the  wrist,  while  the  hand  is  in 
exti'eme  flexion.  Violence  of  a  similar  character,  ajiplied  in  the  opposite  direction, 
will  ]noduce  the  forward  luxation. 

The  diagnosis  must  be  made  between  Colles'  fracture  and  dislocation.  In  dis- 
location the  deformity  from  the  overriding  carpus  is  much  greater  than  after 
fracture.  In  Colles'  fracture  the  swelling  on  the  dorsum  of  the  wrist  is  smooth 
and  rounded.    When  impaction  has  not  occurred  crepitus  may  be  obtained. 

Eeduction  is  effected  by  extension  and  coiinter-extension  from  the  forearm  and 
hand,  to  which  direct  pressure  in  the  line  of  displacement  should  be  added. 

Dislocation  of  the  metacarpal  bones,  at  their  carpal  extremities,  is  rare.  Ijuxa- 
tion  of  the  metacarpal  bone  of  the  thumb  is  most  frequently  observed.  The 
carpal  end  of  this  bone  may  be  displaced  partially  or  completely,  in  a  forward  or 
lackivard  direction.  When  the  end  of  the  bone  rests  upon  the  dorsum  of  the  trape- 
zius it  can  be  easily  recognized. 

Extension  and  counter-extension,  with  direct  pressure,  is  usually  sufficient  to 
accomplish  reposition.  A  clove-hitch  or  snare  may  be  thrown  around  the  thumb 
to  insure  extension.  Eeduction  is  at  times  difficult,  and  the  history  of  this  acci- 
dent is  not  without  a  record  of  failure  both  as  to  replacement  and  retention  when 
replaced. 

In  the  displacement  forward,  on  account  of  the  thickness  of  the  soft  parts,  the 
end  of  the  bone  cannot  be  easily  recognized.  An  unusual  depression  may  be 
observed  on  the  radial  and  dorsal  aspects  of  the  wrist,  just  in  front  of  the  os 
trapezium. 

Strong  extension  with  counter-extension  is  necessary,  and  to  this  should  be 
added  direct  pressure,  applied  near  the  end  of  the  displaced  bone. 

Luxation  of  the  remaining  metacarpal  bones  occurs  rarely,  and,  when  met  with, 
the  displacement  is  usually  partial,  and  toward  the  dorsum  of  the  carpus. 

The  phalanges  may  be  dislocated  either  backivard  or  forward  at  the  metacarpal 
articulations,  or  at  the  interphalangeal  joints.  The  character  of  the  lesion  is 
easily  recognized,  and  the  reduction,  as  a  rule,  is  not  difficult.     Extension  with  a 


194 


THE   JOINTS— DISLOCATIONS 


clove-hitch,  or  with  the  apparatus  shown  in  Fig.  2-15,  will  effect  reduction.  In  some 
instances  operative  interference  is  demanded  when  reposition  by  extension  and 
pressure  cannot  be  effected.     Careful  asepsis  should  be  observed.    On  opening  into 


4^ 


Fig.  245. — (After  Hamilton.) 

the  joint,  the  resisting  ligaments  should  be  snipped  with  a  sharp  bistoury,  when 
the  displacement  may  be  easily  corrected. 

Hip-joint. — While  the  head  of  the  femur  may  be  displaced  from  the  cotyloid 
cavity  in  any  direction,  it  is  customary  to  consider  four  distinct  luxations:  (1) 
Upon  the  dorsum  ilii;  {2)  into  the  ischiatic  notch;  (3)  into  the  obturator  foramen; 
(4)  upo7i  the  OS  pubis.  Practically  these  ■  lesions  occur  in  each  of  the  quadrants 
of  a  circle,  tlie  center  of  which  is  the  center  of  the  acetabulum. 

As  shown  in  Fig.  246,  about  fifty  per  cent  of  all  luxations  at  the  hip  occur  in 
the  iliac  quadrant,  thirty  per  cent  in  the  ischiatic,  eleven  per  cent  in  the  obturator, 

and  seven  per  cent  in  the  pubic.  Two 
per  cent  occur  beyond  these  regions. 
Cases  are  on  record  where  the  head 
of  the  bone  was  lodged  on  the  tuber 
ischii,  in  the  perineum,  and  just  be- 
neath the  anterior  superior  spine  of 
the  ilium. 

The  capsule  is  usually  torn  at  its 
inferior  and  posterior  surface.  It  may 
be  a  slit  or  tear  in  the  long  axis  of  the 
ligament,  or  frequently  a  broad  rup- 
ture occurs  along  the  edge  of  the  coty- 
loid cavity.  The  ligamentum  teres 
(when  present)  is  always  torn.  The 
ilio-femoral  (or  Y)  ligament  is  very 
rarely  completely  ruptured.  The  in- 
jury to  the  muscles  and  surrounding 
structures  is  always  severe,  and  varies 
in  proportion  to  the  degree  of  violence 
which  caiTsed  the  luxation,  together 
with  the  particular  direction  of  the 
displacement. 

In  the  displacement  upon  the  dorsum  ilii  the  glutei  muscles  may  be  lacerated, 
bruised,  or  lifted  from  the  ilium  by  the  head  of  the  bone,  but  not  l3y  tension  on 
their  tendons,  for,  with  the  exception  of  the  lower  fillers  of  the  maximus,  their 
axes  are  slightly  shortened  in  the  new  position.  The  obturator  internus,  externus, 
gemelli,  and  quadratus  femoris  are  greatly  stretched,  or  torn  entirely  loose.  The 
pyriformis  is  not  so  apt  to  suffer.  The  pectineus,  iliacus,  and  psoas  are  carried 
upward  and  outward.  When  the  head  of  the  bone  is  projected  into  the  ischiatic 
notch,  the  conditions  as  to  the  muscles  are  practically  unchanged.  The  sciatic 
nerve  and  vessels  are  pressed  upon  and  may  be  contused  or  lacerated.  In  the  dis- 
placement upon  the  pubes  the  psoas  and  iliacus  may  be  injured,  while  the  femoral 
vessels  and  anterior  crural  nerve  are  more  or  less  pressed  upon.  When  the  head 
of  the  bone  is  lodged  in  the  obturator  foramen,  the  obturator  externiis  muscle  and 
the  obturator  vessels  and  nerves  are  more  or  less  contused,  while  the  glutei  and 
the  remaining  external  rotators  are  put  upon  the  stretch. 

Causes. — Dislocations  at  the  hip  may  be  congenital,  pathological,  or  traumatic 
in  cause. 


/     Ih'ac 

Pubic    \ 

/            50 

r            \ 

\    Ischiatic 

Obturator       \ 

\              JO 

II           1 

Fig.  246. — Showing  the  proportion  of  displacement  in 
the  four  quadrants  of  a  circle  about  the  acetabulum. 


THE   JOINTS— DlSLOCATIOXS 


195 


Congenital  luxations,  rare  in  occmrence,  are  the  result  of  interference  with 
normal  development.  Failure  to  complete  the  process  of  ossification  in  the  three 
bones  which  compose  the  acetabulum  leaves  a  soft  and  fibro-cartilaginous  cup  or 
sac,  throiigh  which,  when  the  weight  of  the  bodj"-  is  sufficient,  the  head  of  the 
femur  is  more  or  less  completely  displaced  into  the  pelvic  cavity.  Abscess  of  the 
ligamentum  teres  is  not  alone  sufficient  to  account  for  displacement  when  the  bones, 
capsule,  and  muscles  are  normal,  for  it  is  not  infrequentlj'  absent  in  cases  which 
have  never  suffered  a  luxation.  Moreover,  the  majority  of  cases  in  which  this 
ligament  has  been  ruptured  by  one  luxation  do  not  suffer  a  second  displacement. 
An  abnonnally  long,  loose,  or  relaxed  capsule  will  lead  to  subluxation  or  displace- 
ment without  rupture  of  the  capsule.  Failure  of  development  from  the  cervical 
epiphysis  is  another  cause  of  congenital  dislocation  at  the  hip. 

Pathologkal  dislocations  are  caused  by  chronic  arthritis.  The  bones  are  more 
or  less  destroj-ed,  and  the  capsule  breaks  down,  permitting  dislocation  of  the  head 
of  the  bone  as  a  resiilt  of  muscular  action  or  slight  violence. 

Traumatic  luxations  are  direct  or  indirect.  The  most  frequent  cause  is  a  fall 
from  a  height  or  from  a  carriage  in  motion,  the  person  striking  upon  the  foot 
or  knee,  witli  the  thigh  carried  in  such  a  direction  that  its  axis  is  at  a  considerable 
angle  to  that  of  the  spinal  column. 

Anatomically  considered,  the  most  favorable  position  for  the  two  posterior,  and 
by  far  the  most  frequent,  displacements  is  when  the  thigh  is  flexed  at  about  an 
angle  of  ninety  degrees  to  the  axis  of  the  body. 
If  the  thigh  l^e  adducted,  the  tendency  is  to  rup- 
ture the  capsule  on  its  posterior  inferior  surface, 
with  escape  of  the  head  on  to  the  dorsum  ilii,  or 
into  the  iscliiatic  notch.  When  in  a  position  of 
abduction,  the  rupture  is  likely  to  occur  on  the 
lower  anterior  aspect  of  the  capsule. 

A  fall  direetl}-  upon  the  trochanter,  with  the 
thigh  in  adduction  or  abduction,  with  extreme 
outward  or  inward  rotation,  is  apt  to  produce 
rupture  of  the  capsule  and  luxation. 

Sym ptoms. — In  dislocation  upon  the  dorsum 
ilii,  with  the  patient  standing  erect  upon  the 
uninjured  extremitv",  the  trochanter  of  the  dis- 
placed femur  will  be  nearer  the  anterior  superior 
spine  of  the  ilium  than  that  of  the  opposite  side; 
the  thigh  is  slightly  flexed  upon  the  abdomen, 
adducted,  and  rotated  inward.  The  head  of  the 
bone  may  be  appreciated  in  the  new  position. 
The  shortening  is  from  one  to  two  inches,  and 
in  the  vast  majoritv'  of  cases  the  great  toe  of  the 
injured  side  is  directed  to  or  rests  upon  the  in- 
step of  the  opposite  foot,  while  the  knee  of  the 
luxated  side  is  in  front  of,  and  slightly  above, 
its  fellow  (Fig.  217).  Muscular  rigidity  and 
fisation  are  extreme.  In  verj'  exceptional  cases 
there  is  eversion  of  the  foot,  with  slight  al^duc- 
tion,  which  Professor  Bigelow  holds  to  be  due 
to  extensive  and  unusual  laceration  of  the  ilio- 
femoral ligament. 

Wlien  the  head  of  the  bone  is  lodged  in  the 
iscliiatic  notch,  the  general  characters  of  the  de- 
formity are  the  same,  yet  not  so  well  marked. 
The  degrees  of  flexion  and  adduction  are  less 
extreme,  the  trochanter  is  less  prominent,  and 
there  is  not  so  much  shortening. 

In  the  thyroid  displacement  the  extremity  is  increased  in  length,  and  the  tliigh 
is  abducted  and  slightly  flexed  upon  the  abdomen.    The  toes  may  be  turned  slightly 


Fig.  247. — Position  of  extremity  in  dis- 
location of  the  head  of  the  femur  upon 
the  dorsum  iliL      (After  Hamilton.) 


196  THE  JOINTS— DISLOCATIONS 

in  or  out,  although  they  usually  point  to  the  front.     The  hip  is  less  prominent 
than  normal.     The  head  of  the  femur  may  at  times  be  recognized  in  the  new  posi- 
tion,  although,    on   account   of   the   tense 
condition  of  the  adductor  muscles,  this  is 
in  some  instances  impossible  (Fig.  248). 


Fig.  248. — Position  of  extremity  in  dislocation  of        Fig.  249. — Position  of  extremity  in  dislocation  of 
the  head  of  the  femur  into  the  thyroid  fora-  the  head  of  the  femur  upon  the  pubes.      (After 

men.     (After  Hamilton.)  Hamilton.) 

AVhen  the  dislocation  occurs  on  the  puhes  there  is  abduction,  slight  fle.xion, 
and  sliglit  outward  rotation.  The  foot  is  carried  away  from  that  of  the  sound 
side,  and  the  toes  are  pointed  outward.  The  chief  diagnostic  feature  of  this 
displacement  is  the  j^resence  of  the  head  of  the  bone  at  Poupart's  ligament 
(Fig.  2-19). 

The  ctifEerential  diagnosis  is  between  muscular  spasm  or  rigidity  and 
fracture. 

Spasm  or  rigidity  of  the  muscles  about  the  hip  may  occur  as  a  result  of  an 
acute  or  subacute  inflammatory  process  in  the  joint,  or  in  the  periarticular  tissues, 
or  in  certain  cases  of  ostitis  of  the  lumbar  vertebrae,  sacrum,  or  ilium,  in  the  neigh- 
borhood of  the  psoas  arid  iliacus  muscles.  This  condition  of  partial  immobility  may 
be  diiferentiated  from  that  of  dislocation  by  the  absence  of  the  shortening,  which 
is  present  in  the  displacement  on  the  dorsum  ilii  and  into  the  ischiatic  notch,  the 
lengthening  in  the  thyroid  luxation,  while  the  head  of  the  bone  on  the  pubes  will 
determine  the  character  of  this  lesion.  The  absence  of  the  characteristic  de- 
formity of  each  of  these  forms  of  dislocation  will  determine  the  diagnosis  of 
muscular  spasm  or  rigidity.     The  symptoms  of  fracture  near  the  hip  have  been 


THE   JOINTS— DISLOCATIONS 


197 


given.     Shortening,  pretertiaiural  mobility,  and  crepitus  are  to  be  chiefly  relied 
upon  in  differentiation.     The  careful  emj^loyment  of  the  X-ray  will  enable  the 
operator   to    determine    the    exact   condition   of 
the  joint. 

Beduction — Dislocation  on  the  Dorsum  Illi 
— Bigelow's  Method. — In  complete  ether  narco- 
sis, place  the  patient  uj)on  a  strong,  low  table, 
or  upon  the  floor,  in  the  dorsal  decubitus.  With 
the  pelvis  held  firmly,  grasp  the  leg  of  the  dis- 
located side  Just  above  the  ankle,  with  one  hand, 
and  near  the  knee  with  the  other,  flex  the  leg 
on  the  thigh,  and  the  thigh  on  the  abdomen,  to 
nearly  an  angle  of  ninety  degrees  with  the  sur- 
face of  the  floor,  adduct  the  tliigh  until  the 
knee  of  this  side  is  carried  to  about  the  middle 
of  the  sound  thigh,  and  then  cause  the  knee  to 
describe  a  circle  outward  and  downward  until 
the  leg  is  brought  to  the  floor  in  its  normal 
position  (Fig.  250).  If  the  luxation  is  not 
reduced  the  manceuvre  should  be  carefully  re- 
peated. This  method  of  reduction  by  manipu- 
lation is  based  upon  the  resistance  to  reduction 
which  is  made  by  the  ilio-femoral  ligament 
(when  this  is  not  torn).  „   ,     .        ,  ,.  , 

^      rm  1  •!■  -c  j-1  •     T  i  ■       1  Fig.  250. — Reduction  of  dislocation  on 

The  normal  position  of  this  ligament  is  shown         ^^e    dorsum  iiii    by  manipulation. 
in  Fig.   251,  and  its  relaxation   by  flexing   the         (After  Bigeiow.) 


Fig.  252. — Relaxation  of  the  ilio-femoral  ligament 
by  flexion  and  adduction  of  thigh.      (Bigeiow.) 

dislocated    thigh    upon    the    abdomen    is 
shown  in  Fig.  252;  and  it  is  readily  seen 
that   if,   with   the   thigh  in  this   position, 
abduction,  with  outward  rotation,  is  prac- 
ticed, the  head  of  the  bone  will  be  lifted 
over   the  margin   of  the   acetabulum   and 
carried  in  the  direction  of   the  socket. 
In  reducing  posterior  dislocations  Prof.  L.  A.  Stimson  says: 
"  The  plan  which  I  have  habitually  employed  for  many  years  is  to  place  the  pa- 
tient face  downward  upon  a  table,  with  his  legs  projecting  so  far  beyond  the  edge  that 
the  injured  thigh  hangs  directly  downward,  while  the  surgeon  grasps  the  ankle,  the 


Fig.  251. — The  ilio-femoral  or  Y  ligament. 
(Bigeiow.) 


198 


THE   JOINTS— DISLOCATIONS 


knee  being  flexed  at  a  right  angle.    The  other  limb  is  held  horizontal  by  an  assistant. 
The  weight  of  the  limb  now  makes  the  needed  traction  in  the  desired  direction,  and 

the  surgeon  has  only  to  wait  for  the  muscles  to 
relax  and  the  bone  to  resume  its  place  with- 
out further  effort  on  his  part  than  a  slight 
rocking  or  rotation  of  the  limb.     Occasion- 
ally I  have  added  the  weight  of  a  small  sand- 
bag at  the  knee  or  have  made  sudden  slight 
jjressure  at  the   same  point.     It  will  often 
succeed  without  anaesthesia,  and  sometimes  so 
quietly  that  there  is  no  jar  or  sound  indicat- 
ing its  return  to  place.     In  only  two 
cases  has  it  failed  in  ni]''  hands;  both 
were  then  reduced  by  traction  in  the 
axis  of  the  partly  flexed  limb." 

Eeduction  of  Dislocations  in  the 
Thyroid  Foramen — Method  of  Bige- 
low. — Place  the  patient  uf)on  the  floor, 
in  the  dorsal  decubitus,  flex  the  leg 
on  the  thigh,  and  the  thigh  on  the 
abdomen,  making,  at  the  same  time, 
slight  abduction.  Then  rotate  the 
femur  inward,  adduct,  and  carry  the 
knee  to  the  floor. 

The  steps  advised  by  Stimson  are 
as  follows : 

1.  Make  strong  traction  in  the  axis 
of  the  limb  as  it  lies,  in  order  to  bring  the  head  below  the  brim  of  the  pelvis ;  it  is 
rarely  necessary  to  aid  this  by  increasing  the  extension,  abduction,  and  outward  rota- 


-Reduction  of  dislocation  into  the  tliyroid 
foramen.      (Brgelow.) 


Fig.  255. — Showing  how  flexion  of  the  thigh  on 
the  abdomen  relaxes  the  ilio-femoral  ligament 
in  dislocation  into  the  thyroid  foramen.  (Bige- 
low.) 

tion.  By  this  means  the  posterior  portion 
of  the  capsule  is  made  tense,  and  its 
point  of  attachment  to  the  back  of  the 
neck  of  the  femur  is  thereby  made  the 
center  for  the  following  movements : 
2.  Pressure  with  the  hand  upon  the  head  of  the  femur  to  prevent  its  return 
upward  during  flexion.     Sometimes  this  is  sufficient  to  make  reduction. 


Fig.  254. — Showing  the  relation  of  the  ilio-femoral 
ligament  in  dislocation  of  the  head  of  the  fe- 
mur into  the  thyroid  foramen.      (Bigelow.) 


THE   JOINTS— DISLOCATIONS  199 

3.  Flexion,  in  order  to  relax  the  Y  ligament;  it  should  not  be  carried  to  a 
right  angle,  otherwise  too  much  strain  will  be  made  upon  the  posterior  portion  of 
the  capsule. 

4.  Eotation  inward,  by  which  the  head  is  returned  to  the  socket. 

The  after-treatment  of  hip-luxation  involves  fixation  of  the  muscles  about  the 
joint  for  from  two  to  six  weeks.  A  gutta-percha,  heavy  pasteboard,  or  leather 
splint,  molded  to  the  side  of  the  pelvis,  thigh,  and  down  to  the  ankle,  applied 
upon  a  thin  layer  of  absorbent  cotton,  and  held  in  place  by  a  leg-,  thigh-,  and  spica- 
bandage,  should  be  employed. 

The  prognosis  as  to  rapid  restoration  of  function  is  not  always  favorable.  The 
injury  to  the  capsule,  and  more  especially  to  the  muscles  around  the  joint,  may 
lead  to  an  impairment  of  the  hip,  more  or  less  permanent.  In  permanent  luxa- 
tions, in  some  iastances,  a  fair  degree  of  mobility  may  be  developed.  Keduction 
has  been  successfully  performed  as  late  as  four  and  six  months  after  the  injury. 

The  treatment  of  congenital  dislocations  of  the  hip,  and  of  pathological  luxa- 
tions, will  be  given  later. 

Dislocations  at  the  Knee — The  Tibia  from  the  Femur. — Displacement  of  the 
femoral  end  of  the  tibia  may  occur  as  a  result  of  congenital  malformation,  disease, 
or  accident. 

Congenital  luxation  is  rare,  and  is  usually  partial.  As  a  rule,  the  tibia  is  dis- 
placed forward,  although  the  opposite  condition  may  prevail.  Absence  of  the 
patella  has  been  observed  in  several  of  these  cases. 

Pathological  dislocations  will  be  given  under  the  head  of  diseases  of  this 
joint. 

Traumatic  luxation  at  the  Ivnee  is  comparatively  rare.  The  tibia  may  be  com- 
pletely or  partially  displaced,  and  in  any  direction.  Partial  dislocation  is  the 
rule.  Complete  luxation  is  apt  to  be  complicated  with  a  wound.  A  compound 
dislocation  usually  occurs  forward  or  backward.  The  cause  is  direct  violence.  A 
blow  upon  the  anterior  aspect  of  the  tibia,  near  the  joint,  or  the  posterior-inferior 
portion  of  the  femur,  may  cause  a  backward  displacement  of  the  tibia,  while  vio- 
lence from  op]30site  directions  may  produce  a  forward  dislocation.  The  same  force 
applied  laterally  may  also  produce  the  lateral  displacements.  A  favorable  condi- 
tion for  luxation  is  the  application  of  violence  when  the  leg  is  in  extreme  flexion. 
A  sudden  twisting  or  wrenching  of  the  femur  upon  the  tibia  when  the  foot  is  so 
caught  that  rotation  on  the  heel  is  impossible,  is  favorable  to  rupture  of  the  liga- 
ments, and  lateral  or  oblique  incomplete  luxation. 

The  symptoms  of  dislocation  at  the  knee  are  usually  clear.  In  the  bad-ward 
variety  the  antero-posterior  diameter  of  the  knee  is  increased,  the  tiliia  projects 
into  the  popliteal  space,  and  the  condyles  of  the  femur  are  unusually  prominent. 
In  the  forward  variety  the  antero-posterior  measurements  are  also  increased,  the 
anterior  edges  of  the  tibia  are  easily  detected  in  the  advanced  position  of  this  bone, 
while  the  condyles  of  the  femur  are  unusually  prominent  posteriorly.  The  tibia 
may  be  rotated  upon  its  axis.  In  the  lateral  displacements  the  condyle  of  the  femur 
is  recognized  as  projecting  on  one  side,  while  the  flat  end  of  the  tibia  is  felt  on 
the  opposite  side.  The  transverse  diameter  of  the  joint  is  increased  in  proportion 
to  the  degree  of  displacement,  which  is,  however,  rarely  complete. 

Treatment. — Reduction  is  readily  effected  by  extension  and  counter-extension, 
with  direct  pressure  and  counter-pressure  in  the  proper  directions.  Once  reduced, 
iLxation  should  be  secured  by  Buck's  extension,  with  sand-bags  applied  to  the  limb, 
or  an  investing  splint  should  be  employed. 

The  prognosis  after  this  injury  is  unfavorable.  The  function  of  the  joint  is 
rarely  fully  restored.  The  question  of  amputation  after  dislocations  of  the  knee, 
where  there  is  extensive  injury  of  the  surrounding  structures,  is  one  of  great  impor- 
tance. Shock  is  more  profound  in  this  luxation  than  in  dislocation  at  any  other 
joint.  A  primary  amputation  will  rarely  be  justified  except  after  laceration  of  the 
popliteal  vessels.  All  antiseptic  measures  should  be  employed,  and  amputation 
only  advised  after  every  effort  consistent  with  the  safety  of  the  patient's  life  has 
been  made.  Exsection  "is  preferable,  and  offers  not  only  a  greater  degree  of  safety 
but  a  more  useful  result. 


200  THE  JOINTS— DISLOCATIONS 

Dislocation  of  the  Patella. — This  bone  may  be  displaced  by  muscular  action, 
witliout  the  aid  of  external  violence,  or  by  an  injury  alone.  When  the  ligamentum 
patellae  is  ruptured,  it  is  carried  upivard  for  a  varying  distance  by  the  contraction 
of  the  quadriceps.  It  can  only  be  displaced  downward  by  a  blow  received  upon  its 
upper  margin  sufficient  to  tear  it  loose  from  its  muscular  attachments.  Dislocation 
outioard  is  the  more  frequent  variety,  and  occurs  as  a  result  of  muscular  contrac- 
tion and  from  violence.  Displacement  inward  is  the  result  of  a  blow  received  iipon 
the  outer  margin  of  the  bone.  In  the  lateral  dislocations,  in  rare  instances, 
the  patella  is  turned  obliquely  on  its  edge,  or  it  may  possibly  be  completely 
inverted. 

The  symptoms  of  these  various  luxations  are  unmistakable,  and  the  reduction, 
by  relaxing  the  quadriceps  and  pressure,  not  difficult. 

The  after-treatment  is  directed  to  the  prevention  of  recurrence. 

Dislocations  at  the  Ankle-joint. — Dislocations  at  the  tibio-tarsal  articulation 
may  occur  in  four  directions,  viz.,  forward,  backward,  inward,  and  outward.  In 
the  last  two  forms  fracture  of  one  or  the  other  malleolus  is  apt  to  occur. 

Dislocation  of  the  tibia  inward  is  caused  by  a  fall  upon  the  foot  at  a  time  when 
it  is  turned  outward,  the  body-weight  being  brought  to  bear  upon  the  inner  aspect 
of  the  heel  and  great  toe.  This  form  of  sprain  is  frequently  caused  by  leaping 
from  a  wagon  or  car  in  motion.  It  may  also  result  from  a  heavy  blow  upon  the 
fibular  side  of  the  leg,  near  the  ankle,  when  the  foot  is  solidly  fixed  against  the 
ground.  The  displacement  is  usually  partial.  A  complete  luxation  is  apt  to  be 
compound. 

The  symptoms  of  inward  dislocation  are  the  great  prominence  of  the  inner 
malleolus  and  the  peculiar  twist  of  the  foot,  so  that  the  inner  side  of  the  heel 
and  the  great  toe  rest  on  the  floor  while  the  sole  looks  obliquely  outward  and 
upward.  The  only  displacement  it  may  be  mistaken  for  is  that  of  the  astragalus 
from  the  os  calcis. 

The  treatment  is  to  bring  the  foot  into  the  normal  position  by  pressure  and 
counter-pressure,  and  fix  it  with  a  splint  and  bandage.  On  account  of  the  great 
swelling  which  is  likely  to  occur,  an  immovable  dressing  should  not  be  a23plied 
until  the  acute  symptoms  of  inflammation  have  subsided. 

The  symptoms  of  outward  displacement  are  the  reverse  of  the  inward,  and  can 
without  difficulty  be  recognized.  Displacement  of  the  tendons  of  the  long  and 
short  peronei  muscles,  from  their  sheaths  behind  the  external  malleolus,  is  likely 
to  occur  in  this  accident.  After  reduction  at  the  joint  these  should  be  pushed  into 
place,  and  an  effort  (rarely  successful)  made  to  hold  them  in  position  bj'  a 
compress  and  bandage,  applied  before  the  splint  for  the  luxation  is  adjusted. 

Forward  dislocation  may  occur  as  the  result  of  a  blow  upon  the  back  of  the 
leg,  near  the  ankle,  while  the  foot  is  firmly  placed  upon  the  ground;  by  falling 
forward  with  great  violence,  when  the  momentum  of  the  body  is  suddenly  arrested 
by  the  foot  striking  against  the  ground ;  or  by  falling  backward,  with  the  foot  so 
fixed  that  great  and  unusual  extension  of  the  tarsus  takes  place. 

The  symptoms  are  unnatural  prominence  of  the  heel  and  shortening  of  the 
distance  between  the  toes  and  the  front  of  the  tibia,  on  the  displaced  side. 

Reduction. — Place  a  clove-hitch  around  the  heel  and  instep  for  extension,  and 
make  counter-extension  from  the  thigh.  Flex  the  leg  so  as  to  relax  the  sural 
muscles,  and  make  forcible  extension  from  the  foot.  As  soon  as  the  extension  is 
well  begun  the  023erator  places  his  foot  against  the  front  of  the  patient's  tibia,  just 
above  the  ankle,  and  pulls  forward  on  the  foot,  at  the  same  time  flexing  it  on 
the  tibia. 

Baclcward  displacement  is  caused  by  violence  applied  in  a  direction  op2:)osite 
to  that  which  produces  the  forward  luxation,  and  the  symptoms  are  exactly  the 
reverse. 

The  treatment  demands  reduction  by  extension  and  counter-extension,  and 
direct  pressure. 

Dislocations  at  the  ankle  are  often  complicated  with  fracture,  or  may  be  com- 
pound. In  any  form  of  injury  an  effort  should  be  made  to  save  the  foot  and  joint. 
The  ankle  is  exceedingly  tolerant  of  surgical  interference,  and,  with  strict  cleanli- 


THE   JOINTS— DISLOCATIOXS  201 

ness  and  antisepsis,  amputation  on  account  of  complicated  or  compiound  dislocation 
will  be  rarely  necessary. 

The  fibu^la  may  be  displaced  from  its  articulation  with  the  tibia  at  its  upper 
or  lower  end.  At  the  upper  end  it  is  usually  luxated  forward,  as  a  result  of  direct 
violence  from  behind,  although  it  is  possible  to  have  the  reverse  occur.  The  bone 
will  be  felt  in  the  abnormal  and  anterior  position,  and  may  be  pushed  directly 
back  into  place.  In  the  backward  displacement  the  biceps  muscle  may  produce 
the  luxation,  or  it  may  be  from  violence  applied  from  the  front.  Strong  and  con- 
tinued pressure  must  be  employed  to  retain  the  bone  in  position  until  adhesions 
occur.  During  the  treatment  the  leg  should  be  flexed  on  the  thigh  in  order  to- 
relax  the  biceps. 

At  the  lower  end  dislocation  of  the  fibula  alone,  without  the  tibia,  is  exceedingly 
rare.  Anatomically,  it  may  occur  in  both  directions.  Eeduction  may  be  aifected 
by  direct  pressure.  The  fibula  may  be  displaced  outward  from  the  tibia  bj'  the 
astragalus  being  driven  upward  between  these  bones. 

Dislocations  of  the  Bones  of  the  Tarsus. — The  astragalus  may  be  partially  or 
completely  dislocated  forward,  backward,  outward,  or  inward.  The  luxation  is 
usually  incomplete.  On  account  of  the  great  violence  necessary  to  its  production 
it  not  infrequently  is  compound,  or  complicated  with  a  fracture.  Violence  of  the 
same  character  as  that  which  produces  displacement  of  the  tibia  will  cause  dislo- 
cation, of  the  astragalus. 

Treatment. — Luxation  of  the  astragalus  is  a  serious  accident.  The  efforts  at 
reduction  do  not  always  succeed,  and,  even  when  reduction  is  effected,  the  injury 
to  the  joint  may  be  such  that  loss  of  frmction  results.  Direct  pressure  and  counter- 
pressure,  while  the  patient  is  profoundly  anEesthetized,  offer  the  best  means  of  suc- 
cessful reduction.  Displacements  of  the  metatarsal  bones  and  phalanges  of  the  toes 
are  treated  in  the  same  general  way  as  described  for  similar  lesions  of  the  hand. 

The  Yertehrce. — Dislocation  may  occur  at  any  articular  surface  of  the  vertebra] 
column.  The  accident  is  always  serious,  the  gravity  being  proportionate  to  the 
degree  of  displacement  and  the  injury  to  the  cord  and  nerves.  Fracture  is  a 
frequent  accompaniment. 

Luxations  are  more  common  in  the  cervical  region.  One  or  both  articular 
processes  may  be  displaced  forward  or  backward  upon  the  vertebra  below.  In  the 
unilateral  displacement  the  fibro-cartilage  between  the  bodies  is  only  slightly  in- 
volved, and,  while  there  is  pressure  upon  the  nerves  passing  out  of  the  inter- 
vertebral foramen,  there  is  no  pressure  upon  the  cord.  In  the  iilateral  form  the 
cartilage  is  torn,  the  body  more  or  less  involved  in  the  luxation,  and  the  cord 
compressed. 

The  causes  are  muscular  contraction,  or  violent  twisting  of  the  neck  by  accident. 

The  symptoms  of  unilateral  displacement  are  pain — which  may  be  referred  to 
the  distribution  of  the  nerves  passing  through  the  intervertebral  foramen  involved 
— at  the  seat  of  luxation  and  rotation  of  the  head,  in  a  forward  dislocation,  so 
that  the  chin  points  to  the  side  opposite  to  that  iipon  which  the  injury  exists. 
"WTien  the  luxation  is  baclm-ard,  the  face  is  turned  toward  the  seat  of  injury.  Par- 
alj'sis  is  proportionate  to  the  compression  or  laceration  of  the  cord  or  nerve  roots. 

In  bilateral  luxation  careful  extension  and  direct  pressure  and  counter-pressure 
should  be  practiced. 

Dislocation  of  the  condyles  of  the  occipital  bone  from  the  atlas,  and  luxation 
at  the  atlo-axoid  joint  with  fracture  of  the  odontoid,  is  exceedingly  apt  to  be  fatal. 

Bihs. — The  ribs  may  be  displaced  from  their  vertebral  articulations.  The  cause 
is  direct  violence,  and  the  displacement  usually  forward.  The  tnie  ribs  may  be 
dislocated  at  the  junction  of  these  organs  with  their  cartilages,  near  the  sternum. 
The  treatment  for  these  luxations  is  the  same  as  for  fracture. 

Pelvis. — The  coccyx  may  be  dislocated  by  a  fall  or  blow  received  directly  upon 
the  tip  of  the  spine.  It  is  very  apt  to  be  complicated  with  fracture.  Displacement 
is  usually  forward.  Pain  is  severe,  on  account  of  pressure  upon  the  nerves.  In 
these  forward  displacements,  the  introduction  of  a  thumb  or  finger  properh'  pro- 
tected in  the  rectum  by  direct  pressure  baclavard  will  replace  the  bone,  which  is 
evident  by  the  instantaneous  relief  from  pain.     Backward  dislocations  should  b^ 


202  THE   JOINTS— DISLOCATIONS 

treated  by  direct  pressure  upon  the  dorsum  of  this  bone.  Any  lateral  displace- 
ments woiild  be  subject  to  the  same  general  method  of  treatment. 

Dislocation  at  the  symphysis  pubis  is  not  accompanied  with  marked  displace- 
ment. The  lateral  movement  of  one  bone  upon  another  will  demonstrate  that 
the  interosseous  ligaments  have  given  way. 

Treatment. — The  dorsal  decubitus  with  lateral  compression  should  be  employed. 
If  this  should  fail  and  the  inconvenience  should  be  such  as  to  demand  an  operation, 
the  bones  may  be  reunited  by  wiring.  Displacements  at  the  sacro-iliac  synchon- 
drosis are  very  rare,  and  are  the  resixlt  of  great  violence,  which  would  almost  of 
necessity  be  complicated  with  fracture.  Any  obscurity  in  diagnosis  may  be  cleared 
away  by  the  employment  of  the  Roentgen  ray.  The  treatment  should  be  rest  and 
immobilization. 

Diseases  of  the  Joints  in  General 

Inflaimnation. — Septic  infection  of  a  joint  may  involve  the  entire  anatomical 
structure  of  the  articulation  (arthritis  or  osteo-arthritis),  or  the  capsule  and  its 
lining  membrane   (syndesmitis),  or  the  synovial  lining  alone   (sjTiovitis). 

The  modern  pathological  definition  of  inflammation  of  a  joint  is  not  complete 
without  infection.  There  is,  however,  a  hypercemia  accompanied  by  heat,  pain, 
redness,  and  swelling,  without  the  demonstrable  presence  of  septic  organisms,  as 
in  the  ordinary  sprain. 

Ti-ue  arthritis  is  caused  by  the  presence  of  certain  infectious  organisms  which 
have  found  their  way  through  the  blood  or  lymph  channels,  as  in  tuberculosis  of 
these  cavities,  gonorrhwal  arthritis  and  suppurating  or  pyogenic  osteo-arthritis; 
or  have  entered  directly  through  a  penetrating  wound  or  after  a  com,pound  dis- 
location. 

The  most  frequent  form  of  joint  disease  is  tuberculosis,  which  in  a  large  pro- 
portion of  cases  becomes  a  mixed  (tubercular  and  pyogenic)  infection.  Colonies 
of  the  bacillus  tuberculosis  may  lodge  on  any  part  of  the  joint  surfaces,  but  usu- 
ally the  original  focus  of  infection  is  in  the  bone,  in  or  on  the  articular  side  of 
the  epiphyseal  line,  and  from  this  starting-point  the  joint  is  gradually  invaded. 

That  form  of  arthritis  due  to  specific  urethritis  will  be  described  elsewhere. 

Sprain. — In  traumatic  synovo-arthritis  there  may  be  simply  a  bruising  of  the 
cartilage  or  an  overstretching  of  the  ligaments,  or  tliese  may  be  more  or  less  sepa- 
rated from  their  bony  attachments,  carrying  generally  with  them  a  crescent  or  rim 
of  bone  torn  from  the  point  of  insertion.  At  other  times  (as  in  Pott's  fracture) 
a  sprain  may  be  complicated  with  a  fracture  of  one  or  more  bones  which  enter 
into  the  composition  of  the  joint. 

The  first  symptom  is  pain  and  swelling,  generally  proportionate  to  the  severity 
of  the  traumatism;  there  ensues  capillary  dilatation  (hyperasmia),  emigration  of 
leucocytes  into  the  intercapillary  spaces,  as  well  as  into  the  cavity  of  the  joint 
in  which  there  is  also  a  transudation  of  serum.  This  fluid  is  not  infrequently  dis- 
colored by  red  blood  corpuscles  or  free  hfematin.  Not  only  is  the  capsule  distended, 
but  frequently  the  communicating  bursse  are  also  abnormally  filled  with  fluid. 
Within  a  f)eriocl  varying  from  a  few  days  to  two  or  more  weeks,  the  inflammatory 
symj)toms  subside,  absorption  of  the  exudate  takes  place,  with  restoration  of 
function. 

Treatment. — The  flrst  essential  in  treatment  of  sprain  is  rest.  This  is  best 
secured  by  the  recumbent  posture  and  elevation  of  the  part  involved.  The  ice-bag 
or  other  method  of  applying  cold  will  be  found  beneficial.  Immobilization  is  best 
effected  by  plaster-of-Paris  dressing,  beneath  which,  over  the  injured  area,  a  con- 
siderable layer  of  absorbent  cotton  should  be  interposed.  At  the  end  of  a  week 
the  fixed  dressing  should  be  removed  and  passive  motion  made.  The  dressing 
may,  as  a  rule,  be  discarded  after  one  or  two  weeks. 

When  infection  supervenes,  in  addition  to  al)Solute  rest,  the  closest  attention 
should  be  given  to  the  general  nutrition  of  the  patient.  If  pain  is  severe,  the 
joint  hyper-distended  and  the  temperature  sufficiently  elevated  to  indicate  marked 
septic  absorption,  the  joint  should  be  aspirated  with  a  large  needle,  washing  the 
cavity  freely  with  normal  salt  solution;  evacuating  this  finally  and  sealing  the 


THE   JOINTS— DISLOCATIONS 


203 


opening  through  which  the  needle  was  introduced.  This  operation  may  be  re- 
peated on  one  or  more  occasions,  and  incision  deferred  until  found  absolutely 
necessary. 

In  gunshot  or  punctured  wounds  of  joints  it  is  advisable  to  appl}^  a  sterile 
dressing,  and  under  no  circumstances  to  probe  or  explore  the  wound  or  cavity;  in 
fact,  to  do  no  surgery  unless  haemorrhage  demands  it  or  unless  infection  has 
occurred. 

Dry  Synovitis,  or  Synovo-arthriiis,  is  occasionally  met  with  in  surgical  practice, 
especially  in  rheumatic  or  gouty  subjects.  It  is  an  iniiammation  of  the  synovial 
membrane  of  the  capsule  in  which  there  is  not  only  no  transudation  of  fluid  into 
the  capsule,  but  the  normal  synovial  secretion  is  diminished,  and  in  many  cases, 
even  when  j^roperly  cared  for,  ends  in  loss  of  function  or  anljylosis.  These  cases 
require  rest  so  far  as  the  joint  is  concerned,  and  an  effort  to  correct  the  diathesis 
which  causes  the  inflammation. 


Diseases  of  Special  Joints 

Of  the  Hip. — ^Arthritis  of  the  hip,  hip-joint  disease  (morbus  coxce,  or  morbus 
coxarius),  is  a  frequent  and  fomiidable  affection,  and  one  which,  in  many  instances, 
will  baflie  tlie  best  medical  and  surgical  care  through  months  and  years  of  suffer- 
ing, ending  in  destruction  of  the  joint,  and  frequently  in  death.  It  is  a  disease 
of  childliood,  occurring  chiefly  in  the  period  of  rapid  growth.  It  rarely  occurs 
after  the  twelfth  year.  It  may  occur  at  any  time  prior  to  this  age,  the  majority 
of  cases  being  between  the  ages  of  three  and  six  years. 

The  pathology  of  morbus  coxce  will  vary  with  the  peculiar  character  of  the 
lesion.  The  morljid  cl^anges  which  occur  in  that  variety  which  is  most  frequently 
met  with  are  those  of  tubercular  osti- 
tis, followed  Ijy  destructive  arthritis. 
The  initial  lesion  occurs  as  an  inter- 
ference with,  or  arrest  of,  nutrition, 
near  the  diaphyso-epiphyseal  cartil- 
age (Fig.  256  a),  due  to  the  lodg- 
ment and  proliferation  there  of  col- 
onies of  bacilli  tuberculosis.  It  may 
begin  on  the  diaphyseal  or  epiphyseal 
side  or  in  the  several  centers  of  ossi- 
fication about  the  same  time.  The 
cancellous  cavities  become  filled  with 
embryonic  cells,  absorption  of  the 
lamellffi  occurs,  the  inflammatory  new 
products  may  undergo  a  slow  process 
of  fatty  metamorphosis,  may  become 
caseous,  or  with  mixed  infection  the 
process  may  terminate  in  pus  forma- 
tion. The  development  of  the  bone 
is  arrested,  the  ostitis,  commencing 
in  the  deeper  portions,  travels  in  all  directions,  destruction  of  the  diaphyso- 
epiphyseal  cartilage  occurs,  with  separation  of  the  epiphyses  (diastasis).  While 
these  changes  are  going  on,  the  lining  membrane  of  the  capsule  becomes  in- 
volved, the  process  being  one  of  chronic  synovitis,  which,  as  has  been  stated, 
terminates  inevitably  in  inflammatory  changes  in  the  tissue  proper  of  the  capsule. 
The  joint  becomes  filled  with  the  products  of  inflammation,  the  capsule,  over- 
distended  and  weakened,  ruptures  either  spontaneously  or  as  a  result  of  motion, 
and  dislocation  may  occur.  With  separation  of  the  epiphysis  and  destruction  of 
the  neck  of  the  femur  shortening  ensues. 

Occasionally  the  initial  ostitis  may  be  situated  in  the  bones  which  form  the 
cotyloid  cavity.  It  is  also  held  that  hip-joint  disease  may,  in  very  rare  instances, 
result  from  a  peri-articular  inflammation. 

»  "The  Hip  and  its  Diseases,"  Bermingham  &  Co.,  New  York,  1884. 


Section  of  normal  femur  of  a  boy  eight 
years  old.      (After  Gibney.)  ' 


204 


THE   JOINTS— DISLOCATIONS 


Causes. — The  causes  of  hip  disease  are  chiefly  predisposing.  Any  dyserasia 
which  impairs  nutrition  in  general  favors  the  lodgment  and  proliferation  of 
the  bacillus  tuberculosis  and  tends  to  destructive  ostitis  and  arthritis.  Trau- 
matism maj',  and  undoubtedly  does,  precipitate  the  inflammatory  process  in  many 
cases,  yet  the  ordinary  violence  to  which  this  joint  is  subjected  will  rarely  induce 
coxitis,  except  in  cliildren  afliected  with  some  constitutional  disease.  Excessive  use 
or  a  blow  may  produce  synovitis,  but,  in  a  healthy  patient,  rapid  recovery  is  almost 
certain.  If  diastasis  occurs  as  a  result  of  accident,  ostitis  ensues,  and  impairment 
of  the  joint  follows,  yet  this  is  an  exceedingly  rare  injury.  Eupture  of  the  liga- 
mentum  teres,  which  must  occur  in  a  traumatic  luxation,  could  not  induce  destruc- 
tive arthritis  in  an  otherwise  healthy  individual. 

The  symptoms  of  hip  disease  are  divisiljle  into  tivo  stages.  The  first  stage  em- 
braces all  the  phenomena  of  inflammation,  up  to  a  positive  and  appreciable  de- 
struction of  the  stiTictvires  which  enter  into  the  formation  of  this  joint.  The 
second  stage  embraces  the  phenomena  of  destruction,  namely,  shortening  of  the 
neck,  diastasis,  rui^ture  of  the  ligamentum  teres  and  cajjsular  ligament,  and 
luxation. 

Among  the  earlier  signs  of  this  disease  is  pain,  referred  directly  to  the  hii> 
joint,  or  it  may  be  to  the  hip-  and  knee-joints,  of  the  afliected  side,  and  in  some 
instances  the  pain  is  felt  ^^'holly  in  the  knee  of  the  same  side.  This  symptom  is 
most  exaggerated  at  night  and  in  the  early  morning  hours,  and  after  the  child 
begins  to  move  about  may  disappear.  The  distribution  of  the  obturator  nerve  to 
both  articulations  will  account  for  the  reflex  sensibility  in  the  laiee.  In  a  certain 
nrmiber  of  cases  the  patients  will  deny  all  sense  of  pain,  and  even  under  pressure 
may  not  exhibit  signs  of  suffering.  In  children  this  effort  at  concealment  (not 
uncommon)  is  incited  by  the  fear  of  being  subjected  to  surgical  treatment.  If,  how- 
ever, a  careful  examination  is  made,  rigidity  of  the  muscles  about  the  hip  will  be 
evident.  In  standing  erect,  the  weight  of  the  body  will  be  brought  upon  the  sound 
extremity,  the  gluteal  fold  on  the  affected  side  is  partially  oljliterated  (Fig.  257), 
and  in  walking  there  is  almost  always  a  perceptible 
limp.  The  iliacus,  psoas,  and  adductor  muscles  are 
usually  in  an  abnormal  state  of  tension;  hence  the 
initial  flexion  of  the  thigh,  and  outward  rotation  or 
eversion  of  the  foot. 


Fig.  257.— (After  Sayre.) 


Fig.  259. — (.A.£ter  Sayre.) 


Eigidity  of  the  psoas  and  iliacus  muscles — one  of  the  more  positive  early  symp- 
toms of  hip  disease — may  be  demonsti-ated  in  the  following  manner:  If  the  patient 
be  stripped  and  laid  flat  on  the  back,  on  a  hard,  level  surface,  and  both  legs  drawn 
up  (Fig.  258),  it  will  be  seen  that  the  sacrum,  spines  of  the  vertebra?,  the  scapula, 
and  occiput  rest  in  contact  with  the  table.     If  the  sound  leg  be  now  extended  and 


THE   JOINTS— DISLOCATIOXS  205 

the  popliteal  space  brouglit  ^ell  dov.ii  against  the  surface  of  the  table,  the  lumbar 
spine  is  only  very  slightly,  if  at  all,  lifted  from  the  table  (Fig.  259).  If  there  be 
rigidity  of  the  muscles  named,  as  a  result  of  hip  disease,  on  the  suspected  side, 
when  the  effort  is  made  to  bring  this  leg  into  a  position  parallel  with  the  sound 
one,  it  irill  be  seen  that  extension  of  the  thigh  is  limited,  and  that  tiie  motion  of 


Fig.  260.— (.Aiter  Sa^Te.) 

the  hip- joint  is  transferred  to  the  lumbar  vertebra,  so  that  when  the  popliteal  space 
touches  the  table  the  lumbar  spines  are  lifted  from  one  to  three  inches  from  the 
surface  (Fig.  260). 

The  duration  of  the  first  stage  varies  from  t\T0  or  three  months  to  as  much 
as  one  year,  and  in  exceptional  cases  longer. 

In  the  second  stage  the  tliigh  is  further  flexed  on  the  abdomen,  adduction  is 
more  pronounced,  and  shortening  is  present  in  a  degree  varying  with  the  extent 
of  destructive  ostitis  in  the  acetabulum,  or  liead  and  neck  of  the  femur,  and  to 
the  character  of  the  luxation.  In  the  usual  position  of  the  foot  of  the  affected 
side,  in  this  stage,  the  great  toe  or  inner  surface  of  the  tarsiis  rests  upon  the  dor- 
sum of  the  well  foot,  or  on  the  spine  of  the  tibia.  The  shortening — which  mav  be 
determined  by  measuring  from  the  anterior  superior  spine  of  the  ilium  to  the 
inner  malleolus — will  vary  from  half  an  inch  to  several  inches.  Xelaton's  or 
Callaway's  test — already  given  in  the  articles  on  fractures  of  the  femur — ^will 
demonstrate  that  the  sliortening  lias  occurred  above  the  trochanter. 

Wlien  suppuration  occurs,  the  capsule  gives  way,  and  sooner  or  later,  if  surgical 
interference  is  delayed,  sinuses  open  tlirough  the  skin,  about  the  trochanter,  or 
in  the  groin.  Perforation  of  the  acetabulum  takes  place  in  a  certain  proportion 
of  cases. 

Diagnosis. — Disease  of  the  hip-joint  may  be  difEerentiated  from  bursitis,  peri- 
articular inflammation,  rheumatism,  neuralgia,  sacro-iliac  disease,  or  ostitis  of  tlie 
trochanter  or  ilium.  It  is  also  important  to  determine  whether  the  initial  lesion  is 
a  synovitis  or  an  ostitis. 

Synovitis  may  be  caused  by  excessive  use  of  the  joint,  by  strain  or  concussion, 
by  siidden  exposure  to  cold,  or  it  may  result  as  a  s^nnptom  of  gout  or  rheumatism. 
It  is  a  painful  affection  from  its  incipiency,  and  the  pain  increases  with  the  march 
of  the  effusion  into  the  joint  and  the  distention  of  the  capsule.  Motion  increases 
the  pain,  which  is  usually  so  severe  that  all  movement  of  the  joint  is  firmly  re- 
sisted. The  cause  may  usually  be  traced  to  an  injury.  Synovitis  due  to  gout  or 
rheumatism  occurs  usually  in  adults;  coxitis  is  practically  a  disease  of  childhood. 

When  ostitis  is  the  initial  lesion,  the  approach  of  the  disease  is  insidious  and 
much  less  painful.  Wlien  present,  the  pain  in  ostitis  of  the  head  and  neck  of  the 
femur  is  deep-seated  and  dull,  and  motion  is  comparatively  free.  Eolation  and 
pressure  of  the  head  upon  the  capsule  and  in  the  acetabulum  do  not  produce  the 
sharp  sense  of  pain  felt  in  sj-novitis.  Ostitis  is  the  rule  ia  children,  s^Tiovitis  in 
adults. 

Bursitis  about  the  hip  is  rare.  The  sac  between  the  capsule  and  the  conjoined 
tendon  of  the  psoas  and  iliacus  muscles,  and  those  situated  between  tlie  tendons  of 
the  gluteiTS  maximus,  medius,  and  minimus  and  the  great  trochanter,  and  that 
between  the  quadratus  femoris  and  the  lesser  trochanter,  maj-  one  or  all  be  in- 
volved. Inflammation  in  one  or  more  of  these  bursse  may  be  recognized  by  the 
limited  extent,  as  well  as  the  acuteness  of  the  pain  elicited  by  direct  digital  pres- 
sure immediately  over  the  known  position  of  the  sac.  Pain  in  the  knee  is  not 
present  in  bursitis  at  the  hip.  Eigidity  is  not  general  in  the  muscles  about  the 
joint. 


206  'THE  JOINTS— DISLOCATIONS 

Peri-articular  inflammation  is  a  painful  affection,  causing  marked  lameness 
from  the  start;  it  is  accompanied  by  local  swelling  and  tenderness  if  superficial, 
and  iTsually  by  exacerbations  of  temj^erature,  all  of  which  will  render  it  easy  of 
recognition. 

Muscular  rheumatism  is  rarely  confined  to  the  muscles  of  the  hip.  It  is  an 
expression  of  a  constitutional  condition  which  cannot  but  be  elicited  by  a  careful 
liistory  and  stiidy  of  the  case.  The  pain  is  more  severe  and  more  earljr  recognized 
than  in  coxitis.  The  painful  territory  may  be  outlined  by  fixation  of  the  joint 
and  digital  jwessure  upon  the  muscles  involved. 

Neuralgia  occurs  very  rarely  in  children,  in  the  period  when  hip  disease  is  most 
likely  to  appear.  The  exacerbations  of  pain  are  more  sudden  in  development  and 
acute  in  character,  and  occur  with  greater  freqiiency  and  regularity  tlian  in  hip 
disease.  Motion  is  tolerated  better  in  neuralgia  than  in  coxitis.  Tlie  symptoms 
of  ostitis  whieli  lead  to  arthritis,  if  carefu.lly  studied,  will  show  a  wide  difference 
from  neuralgia  about  the  hip.  ■^' 

In  arthritis  or  ostitis  at  the  sacro-iliac  junction  pain  is  caused  by  forcibly  i:)ress- 
ing  tlie  ilium  against  the  sacrum.  The  same  symptoms  may  be  elicited  by  direct 
pressure  posteriorly  over  the  sacro-iliac  articulation.  Motion  at  tlie  hip  is  only 
slightly  if  at  all  embarrassed. 

Prognosis. — In  hip-joint  disease  commencing — as  is  the  i-ule— in  ostitis  or  cpi- 
physitis,  the  prognosis  is  bad  as  regards  restoration  of  function.  Partial  or  com- 
plete ankylosis,  with  a  variable  degree  of  shortening,  will  result,  in  the  vast 
majority  of  cases,  no  matter  liow  skillfully  treated.  The  proportion  of  fatal  cases 
can  scarcely  be  determined.  It  is  safe  to  say  that  at  least  five  per  cent  of  all  cases 
in  which  the  lesion  begins  as  an  ostitis  end  in  death  in  from  one  to  six  years. 

In  traumatic  s3Tiovitis  of  the  hip  the  prognosis  is  favorable.  A  restoration  of 
function  is  the  rule. 

Treatment. — The  treatment  of  hip  disease  may  be  divided  into  nieclianical, 
operative,  and  constitutional. 

In  tlie  early  stage  of  coxitis  rest  to  the  inflamed  articulation,  in  the  position 
of  least  discomfort,  is  essential.  A  diseased  joint  demands  protection  not  only  from 
traumatism  in  the  effort  at  locomotion,  but  from  reflex  and  involuntary  muscular 
spasm.  Fixation  of  the  muscles  which  act  upon  and  about  this  joint  can  be  best 
secured  by  extension  from  the  lower  part  of  the  thigh  and  counter-extension  from 
the  perinseum.  It  has  been  shown  by  Bradford  and  Lovett,  of  Boston,  that  in 
order  to  gain  the  full  benefit  of  extension  at  the  hip,  the  femur  should  not  be 
brought  out  entirely  straight,  but  should  rest  about  five  degrees  short  of  full 
extension  (175°). 

If  a  child  with  hip  disease  be  seen  very  early  in  the  history  of  this  affection, 
flexion  of  the  thigh  upon  the  abdomen  will  not  have  occurred  to  any  extent,  but, 
in  cases  where  the  inflammatory  process  has  gone  on  for  some  time,  the  iliacus  and 
psoas  and  adductor  muscles  will  have  become  rigid  and  shortened  to  such  an  extent 
that  the  thigh  cannot  be  immediately  brought  out  straight. 

In  the  former  class  of  cases  the  apparatus  about  to  be  described  can  be  at  once 
adjusted;  in  the  latter,  extension  in  the  i-ecumbent  posture  is  necessary  until  the 
shortening  in  the  ilio-psoas  muscles  is  overcome. 

In  fact,  since  in  all  eases  some  time  must  elapse  between  the  discovery  of  the 
lesion  and  the  preparation  of  the  mechanical  apparatus,  it  is  a  wise  practice  to 
put  the  patient  to  bed  at  once,  and  apply  the  extension  as  follows:  Cut  two  strips 
of  moleskin  plaster  from  one  inch  and  a  half  to  two  inches  wide,  and  long  enough 
to  extend  from  six  inches  above  the  trochanter  to  below  the  sole  of  the  foot.  Adjust 
one  to  the  outer  and  one  to  the  inner  aspect  of  the  thigh,  allowing  the  upper 
end,  which  is  to  be  doubled  back  upon  itself  and  woven  in  with  the  roller,  to 
extend  four  or  five  inches  above  the  level  of  the  trochanter.  Mold  them  carefully 
to  the  contour  of  the  limb,  bringing  the  strips  exactly  over  the  inner  and  outer 
condyles  of  the  femur,  and  hold  them  by  a  well-adjusted  bandage,  beginning  from 
above.  In  order  to  prevent  the  plaster  from  wrinkling,  it  is  necessary  to  clip  it 
with  the  scissors,  obliquely  upward  from  each  edge,  at  intervals  of  an  inch  or 
two.     As  the  extension  is  exerted  only  from  the  femur,  the  adhesive  strij^s  should 


THE   JOINTS— DISLOCATIONS, 


m 


not  be  applied  to  the  skin  below  this  point.  The  bandage  is  commenced  just  at  the 
level  of  the  great  trochanter,  and  that  portion  of  the  strips  which  extends  above 
this  is  to  be  turned  down  and  worked  in  with  the  roller. 

That  part  of  the  plaster  which  is  exposed  from  the  knee  down  should  Ije  doubled 
by  laying  a  second  strip  of  equal  width  on  this,  tlie  adhesive  surfaces  coming 
together.  In  this  way  it  is  not  only  strengthened,  but  is  prevented  from  sticking 
to  the  dressing. 

The  extension  weight — varying  from  seven  to  fifteen  pounds — is  applied  as  in 
Buck's  apparatus.  The  dorsal  decubitus  should  be  maintained,  for,  if  the  sitting 
posture  is  assumed,  the  iliacus  and  psoas  muscles  are  not  materially  affected  by 
the  extension.  To  secure  this  result  the  long  splint  of  Hamilton  should  be  applied 
from  the  axilla  along  the  thigh  and  leg,  and  firmly  secured  by  a  bandage  carried 
around  the  chest,  pelvis,  and  thigh.  Or  a  pillow  slij)  may  be  pinned  to  either  side 
of  the  bed,  passing  over  the  chest. 

As  soon  as  the  thigh  is  fully  extended  the  following  mechanism  should  be  ad- 
justed. It  embodies  the  principle  of  extension  from  the  pelvis  and  counter-exten- 
sion applied  to  the  femur  from  the  trochanter  down  to  the  condyles.     It  can  be 

so  arranged  as  to  take  advantage  of  any 
degree  of  deformity,  correcting  flexion, 
abduction  or  adduction.  It  consists, 
first,  of  a  pelvic  band  (Fig.  261)  so 
curved  behind  and  in  front  as  to  make 


Fig.  261. — Shaffer's  modification  of  Taylor's  liip 
splint. 


Fig.  262. — Four-tailed  adhesive  strip,  - 
ready  for  application. 


the  shortest  possible  perineal  pads.  This  band  should  be  made  of  annealed  steel 
strong  enough  to  bear  the  weight  of  the  body  of  the  patient.  Attached  to  this 
is  the  cylinder  which  extends  down  the  leg  along  the  outer  side  to  a  point  oppo- 
site the  ankle-joint.     Accurately  fitted  into  the  cylinder  is  a  traction  rod  with  a 


208 


THE  JOINTS— DISLOCATIONS 


foot  piece,  and  the  connection  between  the  cylinder  and  the  traction  rod  is  regu- 
lated by  an  adjustable  rack  and  pinion.  The  pelvic  band,  accurately  adjusted, 
is  fixed  by  two  short  perineal  pads  attached  to  it  in  front  and  behind,  and  the 
entire  leg"  is  connected  with  the  traction  rod  by  adhesive  plasters  which  envelop 
it  entirely  and  extend  high  up  on  the  thigh,  making  practically  all  the  traction 


Fig.  263. — Showing  the  manner  in  which  the  tails  are  interwoven.     First  step. 

from  above  the  knee.     The  connection  between  the  adhesive  plasters  and  the  foot 
piece  is  made  by  leather  straps   (Fig.  261). 

This  apparatus  may  be  used  in  varioris  modifications,  not  only  in  the  treatment 
of  the  deformity,  but  after  the  deformity  has  been  modified,  in  which  latter  case  it 
is  so  adjusted  that  the  weight  of  the  body  falls  entirely  upon  the  perineal  straps — • 
in  other  words,  forming  a  double  ischiatic  crutch.  When  the  deformity  is  removed 
or  essentially  modified,  the  patient  may  walk  with  or  without  crutches,  as  the  con- 
ditions may  demand.  After  a  certain  length  of  time  has  elapsed,  the  joint  reaches 
a  stage  of  convalescence  where  simple  protection  is  necessary  rather  than  traction. 
The  modified  apparatus  then  becomes  very  useful.  The  modification  consists  in 
adjusting  the  foot  piece  and  cylinder  into  a  well-fitting  shoe,  which  takes  the  jjlace 
of  the  adhesive-plaster  traction.    The  end  of  the  cylinder  is  inclosed  in  the  shoe 


Fig.  264. — The  same,  before  the  bandage-roller  is  applied.     Second  step. 

worn  by  the  patient  instead  of  passing  on  the  outer  side,  and,  in  addition  to  the 
outer  bar,  an  inside  bar  is  added  with  thigh  and  calf  bands  and  an  automatic 
knee  spring,  which  enaljles  the  patient  to  bend  the  knee  as  occasion  may  require. 
It  has  the  same  hip-joint  and  perineal  pads,  and  affords  a  modified  traction  sup- 
port to  the  hip-joint.  When  strong  abduction  is  necessary  the  instrument  shown 
in  Fig.  265  will  be  found  useful. 

Among  many  orthopaadie   specialists   the   question   of  preference  between  this 


THE  JOIXTS— DISLOCATIONS 


209 


form  of  apparatus  and  some  modifieation  of  H.  0.  Thomas'  method  of  treating 
hip-joint  disease  is  not  easily  decided.  Of  all  the  applications  of  Thomas'  idea 
which  have  been  carried  into  effect,  the  following  is  the  most  commendable:  It 
consists  of  a  long  malleable  iron  bar,  which  extends  from  near  the  axilla  down 
the  back  parallel  with  the  spinal  column,  over  the  buttocks,  and  down  the  posterior 
aspect  of  the  thigh  and  leg,  curving  beneath  the  heel,  and  tenninating  opposite 
the  center  of  the  plantar  arch  (Fig.  2G7).  At  this  termination  a  crossbar  from 
three  to  four  inches  long  is  welded,  from  the  tips  of  which  the  extension  straps 
are  adjusted.  At  the  upper  end  of  this  perpendicular  bar  there  is  a  metal  bar  or 
belt  wliich  encircles  the  thorax  for  two  thirds  of  its  circumference,  terminating  in 
straps  of  strong  webbing  fastened  together  with  a  buckle.  At  a  point  opposite  the 
anterior  superior  iliac  spine  a  pelvic  band,  similar  in  construction  to  the  thoracic 
band,  is  adjusted  for  fastening  the  instrument  around  the  pelvis  at  the  iliac 
prominences.  To  this  band  buckles  are  attached  behind  and  in  front  for  double 
perineal  pads.  Opposite  the  gluteal  fold  a  metal  band  is  attached,  which  en- 
circles the  thigh  at  this  point.  Farther  down,  at  the  junction  of  the  inferior 
with  the  middle  third  of  the  til^ia,  another  metal  band  is  attached.  When  ad- 
justed accurately  to  the  contour  of  the  back,  buttock,  thigh,  and  leg,  it  should  ex- 
tend three  inches  below  the  extremity,  so  that  when 
the  patient  stands,  the  instrument  will  rest  upon 
the  floor  while  the 
foot  swings  free 
and  clear. 


-Shaffer's  abduction  hip 
aj^paratus. 


Fig,  2G6.— Thomas'  liip  splint. 


Fig.  267.  —  Thomas' 
hip  splint  (with  Amer- 
ican extension). 


The  apparatus  is  applied  as  follows :  The  four-tailed  adhesive  plasters  are  ap- 
plied to  the  leg  as  above  directed;  the  splint  is  then  adjusted  by  fastening,  first, 
the  perineal  straps  snugly,  so  that  the  pelvic  band  will  come  just  below  or  on  a 
level  with  the  anterior  superior  spines ;  the  thoracic  and  pelvic  Imnds  are  connected 
by  means  of  the  webbing  straps ;  the  leather  straps  attached  to  the  foot  piece  of  the 
brace  are  then  fastened  into  the  buckles  attached  to  the  p)laster  on  the  leg,  and  firm, 
steady  traction  made.  The  entire  limb  and  brace  are  then  incased  in  a  lightly 
applied  muslin  bandage  so  as  to  prevent  any  wabbling  of  the  limb.    A  high  shoe 


210 


THE  JOINT&— DISLOCATIONS 


is  adjusted  to  the  opposite  limb,  and  the  patient  allowed  to  walk  with  this  and 
a  pair  of  crutches. 

The  length  of  time  for  which  this  treatment  should  be  continued  will  be  deter- 
mined by  the  result  achieved.  It  is  often  a  necessity  for  one,  two,  or  three  years, 
and  sometimes  even  longer,  and  should  be  worn  for  several  months  after  all  active 
symptoms  of  coxitis  have  disappeared. 

Conditions  may  arise  in  which  the  apparatus  just  described  cannot  be  applied. 
A  fairly  good  substitute,  and  one  which  secures  fixation,  is  the  plaster-of-Paris 
dressing,  which  is  applied  from  the  line  of  the  nipple  around  the  abdomen  and 
over  the  hip,  thigh,  and  leg,  including  the  foot  of  the  affected  side.  In  order  to 
apply  it  while  the  leg  is  in  a  condition  of  fairly  good  extension,  the  patient  may 
be  made  to  stand  on  the  sound  foot  upon  an  elevated  stool,  allowing  the  lame  foot 
to  be  pendant.  An  assistant  on  either  side  holds  the  patient  upright,  and  another 
makes  traction  do^Tiward  as  the  plaster  is  applied.  The  bony  prominences  should 
be  carefully  padded.     The  child  should  be  allowed  to  go  about  after  the  plaster 

has  hardened,  and  should  wear  an  elevated 
shoe,  four  or  five  inches  high,  on  the  sound 
foot.  This  will  i^ermit  locomotion  with- 
out danger  to  the  integrity  of  the  affect- 
ed hip. 

Yanee,  of  Louisville,  Ky.,  has  invented 
a  molded-leather  splint,  which  is  applied 
in  the  same  way,  and  covers  the  abdomen, 
hip,  and  thigh  down  to  and  below  the 
knee,  and  answers  the  same  purpose  as 
the  plaster-of-Paris;  but  as  this  latter  is 
so  much  more  readily  obtained  and  more 
generally  applicable,  it  may  be  relied  upon 
in  the  early  stages  of  hip-joint  disease  and 
in  the  later  stages  after  extension  and 
counter-extension  in  dorsal  decubitus  has 
brought  the  leg  down  to  the  proper  plane. 
When  sinuses  exist  as  a  result  of  dis- 
ease of  the  hip-joint,  some  slight  change 
in  the  application  of  the  apparatus  select- 
ed will  be  necessary.  It  is  always  essential 
that  the  openings  of  the  sinus  or  sinuses 
be  properly  protected  by  absorbent  dress- 
ings in  such  a  way  that  free  discharge 
may  be  secured  without  soiling  the  ap- 
paratus. 

The  constitutional  treatment  of  this 
disease  is  of  great  importance.  Carefully 
selected  diet,  out-of-door  life,  cod-liver  oil, 
the  hypophosphites  of  lime  and  soda,  and 
tonics  are  indicated. 

In  the  second  stage  of  hip  disease  op- 
erative interference  may  in  rare  cases  be 
demanded:  (1)  To  relieve  jDain  on  account  of  suppuration  and  the  retention  of  pus, 
or  to  prevent  sepsis  from  insufficient  drainage;  (3)  to  arrest  ostitis  in  the  head 
and  neck  of  the  femur,  and  in  the  acetabulum. 

When  pain  is  so  severe  that  fixation  with  extension  will  not  afford  relief,  it  is 
safe  to  conclude  that  distention  of  capsule  exists,  or  that  in  the  structures  which 
form  the  joint,  or  are  immediately  around  it,  su23i3uration  has  occurred  to  such  a 
degree  that  free  incision  is  necessary. 

The  question  of  performing  a  radical  excision  of  the  hip-joint  is  one  upon 
which  a  divergence  of  opinion  still  prevails.  I  am  convinced,  however,  that  this 
operation  should  not  be  done  except  as  a  last  resort  and  when  the  symptoms  of 
septic  absorption  are  so  well  marked  and  severe  that  radical  interference  is  de- 


-Plaster-of-Paris  splint  with  suspen- 
sion in  hip  disease. 


THE  JOINTS— DISLOCATIONS 


211 


manded.  Careful  conservative  treatment  by  -well-adjusted  apparatus,  incision  and 
drainage  of  all  pus  accumulations,  and  careful  general  treatment  of  these  patients 
will  result  not  only  in  securing  the  recovery  of  the  patient,  but  will  give  a  more 
useful  joint  in  the  vast  majority  of  cases.  In  the  rare  cases  in  which  excision  of 
the  hip-joint  is  deemed  necessary  the  wound  should  be  packed  with  iodoform  gauze 
and  treated  by  the  open  method,  not  even  partially  closed  hj  sutures. 

The  gauze  may  be  changed  every  few  days,  the  wound  irrigated  with  1-.3000 
sublimate  solution,  and  again  filled.  Extension  by  the  weight  and  pulle}^,  in  the 
dorsal  decubitus,  is  necessary  for  from  three  to  six  weeks  after  the  operation,  unless 
the  child  is  strapped  in  the  wire  breeches  recommended  b)''  Professor  Sayre   (Fig. 

269)    immediately   after    the   exsection. 
The  chief  recommendation  of  this   ap- 
1\  paratus  is  that  it  allows  the  patient  to 

be  carried  out  of  doors  or  about  the 
house  with  perfect  freedom  from  motion 
or  pain.  The  objection  i.s  its  costliness, 
■nhicli  puts  it  out  of  the  reach  of  many 
patients.  The  extension  in  bed  is  very 
satisfactory  in  its  results,  and,  with  at- 


FiG.  269. — (After  .Sa}Te.) 


Fig.  270.— (After  SajTe.) 


tention  to  ventilation  and  the  amusement  and  entertainment  of  the  little  patient, 
the  confinement  need  not  be  a  formidable  objection. 

"When  the  wire  apparatus  is  used  the  following  directions  should  be  carried 
out :  Pad  the  instrument  well,  so  that  too  great  pressure  at  an_Y  one  point  may  not 
occur.  Place  the  patient  in  it  so  that  the  anus  will  project  well  over  the  crotch. 
It  is  well  to  insert  a  piece  of  protective  under  the  sacrum  and  buttocks  to  prevent 
soiling.  Fasten  the  well  leg  and  the  body  to  the  instrument  by  rollers.  Lay  the 
extremity  of  the  affected  side  in  its  splint,  and  screw  the  foot  piece  up  until  it 
touches  the  sole.  Apply  two  strips  of  adhesive  plaster  in  the  same  manner  as 
heretofore  given,  attacli  these  to  the  foot  piece,  and  make  the  necessary  extension 
by  turning  the  screw  in  the  proper  direction  (Fig.  270).  After  from  four  to  six 
weeks,  no  matter  whether  the  wire  apparatus  is  used  or  extension  in  bed  employed, 
the  long  splint  of  Shaffer  or  Thomas  or  the  high  shoe  and  crutches  should  be 
adjusted,  and  the  case  treated  as  given  for  the  first  stage. 

Within  the  last  few  years  the  operation  of  drilling  into  the  neck  and  head  of 


212  THE  JOINTS— DISLOCATIONS 

the  femur,  in  certain  cases  where  the  initial  lesion  is  an  ostitis,  has  been  advocated 
and  performed  in  a  number  of  instances  by  Mr.  Macnamara.^  The  object  of  the 
operation  is  to  give  escape  to,  and  secure  drainage  of,  the  products  of  the  inflam- 
matory process,  at  or  near  the  epiphysis,  and  tlius  prevent  disintegration  of  tlie  bone 
and  invasion  of  the  Joint.    To  be  beneficial  it  must  be  done  early  in  the  disease. 

The  operation  is  neither  dangerous  nor  difficult.  A  longitudinal  incision,  from 
two  to  three  inches  in  extent,  is  made  along  the  middle  of  the  trochanter,  down 
to  the  bone.  The  wound  should  be  deep  enough  to  permit  the  fingers  to  locate  the 
neck  of  the  femur,  on  its  upper  and  lateral  surfaces,  so  that  the  drill  may  be 
directed  along  its  center.  The  chief  danger  to  he  avoided  is  entering  the  cavity 
of  the  Joint  by  carrying  the  drill  too  far.  The  small  Volkmann  spoon  is  well 
adapted  to  this  operation. 

Knee-joint. — Acute  synovitis  of  the  knee  is  frequently  of  traumatic  origin, 
resulting  from  the  excessive  strain  to  which  this  Joint  is  subjected,  and  also  on 
account  of  its  exposed  position.  It  may  occur  in  the  history  of  gout,  rheumatism, 
gonoiThoea,  and  other  diseases. 

The  chief  symptoms  are  pain  and  swelling.  Pain  may  be  elicited  by  motion, 
or  by  direct  pressure  at  any  part  of  the  Joint,,  but  it  is,  as  a  rule,  emphasized  over 
the  coronoid  ligaments,  along  the  articular  margin  of  the  tibia,  on  either  side  of 
the  ligamentum  patellce. 

The  treatment  consists  of  rest  by  fixation.  As  a  rule,  the  most  agreealjle  posi- 
tion is  that  of  slight  flexion,  with  the  limb  elevated  and  the  leg  resting  over  a 
pillow.  Fixation  may  be  best  secured  by  extension  from  adhesive  strips,  reaching 
from  Just  below  the  knee  to  beyond  the  sole.  The  weight  will  vary  from  three  to 
fifteen  pounds,  according  to  the  age  of  the  patient.  It  must  not  be  forgotten  that 
the  ligaments  of  the  knee-joint  are  susceptible  of  overstretching  from  too  great  and 
]irolonged  extension.  Permanent  relaxation  or  flail  Joint  may  result  from  over- 
weight employed  for  too  long  a  time.  Cold,  applied  l)y  means  of  the  ice-bag,  is  a 
most  useful  remedy  during  the  acute  stage  of  inflammation.  When  pain  is  very 
severe,  and  when  the  capsule  is  greatly  distended,  aspiration  may  be  indicated. 
This  should  be  done  with  all  antiseptic  precautions,  and  with  great  care  in  pre- 
venting the  entrance  of  air.  The  needle  may  be  introduced  on  either  side  of  the 
patella,  at  the  point  of  greatest  distention,  or  where  fluctuation  is  most  marked. 
The  diagnosis  may  be  made  positive  by  a  small  exploring  hypodermic  needle  and 
aspirator.  Or,  when  the  tumefaction  is  evident  above  the  patella,  the  needle  may 
be  carried  from  above  downward,  behind  this  bone.  After  the  excess  of  fluid  is 
withdrawn  a  fair  degree  of  compression  should  be  exercised  by  enveloping  the  Joint 
with  borated  cotton,  held  firmly  down  by  a  roller.  Passive  motion  of  the  Joint  may 
be  omitted  for  as  long  as  six  weeks,  witli  or  without  a  fixed  dressing  as  may  be 
required. 

When  an  acute  synovitis  of  the  knee  becomes  infected  and  pus  is  present,  incision 
and  evacuation  of  the  pus,  with  irrigation,  and  drainage  of  the  Joint  are  indicated. 
As  a  rule,  a  single  lateral  incision  made  near  the  posterior  level  of  the  Joint,  as  the 
patient  rests  in  the  recumbent  posture,  will  suffice.  A  sterile  rubber  drainage 
tube,  about  two  inches  long  with  a  diameter  of  a  quarter  of  an  inch  and  stiff  enough 
to  resist  being  occluded  by  contraction  of  the  incision,  should  be  inserted.  The 
Joint  may  be  irrigated  as  often  as  indicated,  probably  once  a  day,  with  salt  solu- 
tion. When  pus  ceases  to  flow,  the  tube  may  be  removed  and  a  small  catgut  bundle 
drain  inserted  for  from  two  to  six  days. 

The  danger  of  ankylosis  after  acute  synovitis  of  the  knee-joint,  lasting  not 
longer  than  from  one  to  six  weeks,  is  slight.  It  is  always  great  after  suppurative 
synovo-arthritis,  or.  osteo-arthritis. 

Chronic  Effusion  in  the  Knee-joint. — Following  gonococcus  infection,  and  not 
infrequently  when  this  disease  has  not  existed,  a  persistent  transudation  into  the 
capsule  of  the  knee-joint  may  be  present.  This  fluid  varies  in  color  from  a  pale 
amber  to  a  darkish  brown,  and  is  at  times  so  viscid  that  it  will  not  flow  through 
an  ordinary  canula.    It  is  almost  always  an  accompaniment  of  general  malnutrition, 

>  "Gibney  on  the  Hip,"  Berminghara  &  Co.,  New  York,  1884. 


THE  JOINTS— DISLOCATIONS  213 

and  local  measures  are  not  apt  to  be  successful  unless  combined  with  general  con- 
stitutional treatment.  The  transudate  has  its  origin  from  the  endothelia  lining 
the  general  sj-novial  surface  of  either  the  quadriceps  bursa  or  the  capsule,  and 
also  from  the  synovial  fringes  beneath  the  patella. 

Treatment. — Under  strict  asepsis  an  incision  should  be  made  upon  the  outer 
or  inner  lateral  aspect  of  the  Joint,  at  that  point  where  the  fluid  can  be  most 
readily  reached,  usually  at  the  level  of  the  upper  margin  of  the  patella.  All  bleed- 
ing should  be  arrested  before  the  capsule  is  incised.  When  this  is  done  a  thorough 
irrigation  of  the  entire  joint  and  bursa  cavities  should  be  made  with  normal  salt 
solution  at  a  temperature  of  115°  F.,  the  pressure  being  sufficient  to  hyperdistend 
the  sac.  A  small  swab  of  gauze  is  now  securely  held  in  a  suitable  clamp  or  forceps, 
and  with  it  introduced  through  tlie  incision  the  lining  membrane  of  the  quad- 
riceps bursa,  capsule,  and  the  patella  fringes  are  scraped.  Some  bleeding  usually 
follows  this  procedure,  but  it  is  readily  arrested  by  repeating  the  hot  salt  solution 
irrigation,  wliich  should  be  continued  for  five  or  ten  minutes  in  order  to  thor- 
oughly cleanse  the  joint.  The  excess  of  fluid  is  now  pressed  out,  the  capsule  closed 
by  a  chromicized  catgut  running  suture,  with  which  the  superficial  incision  is 
also  reunited.  A  light  gauze  dressing  with  cotton  batting  over  this  and  a  snug 
immobilization  gypsum  cast  is  applied  from  near  the  ankle  to  half-way  up  the 
thigh.  The  general  nutrition  of  the  patient  should  be  carefully  prescribed.  The 
joint  should  remain  inmiobile  for  five  or  six  weeks,  and  then  gradually  permitted 
to  resume  its  normal  function.  Should  this  operation  and  treatment  fail,  it  should 
be  repeated  by  larger  incision  on  each  side,  and  the  fringes  of  the  patella  entirely 
removed. 

Destructive  osteo-arthritis  of  the  knee-joint  may  commence  as  a  sjTiovitis, 
either  traumatic  or  idiopathic,  or  it  may  begin  as  an  ostitis  (tuberculous)  in  or 
near  the  epiphysis  of  the  tibia  or  femur,  the  joint  being  secondarily  involved. 
The  latter  is  by  far  the  more  frequent  source  of  chronic  knee-joint  disease. 

Symptoms. — Pain  is  not,  as  a  rule,  a  prominent  symptom  of  ostitis  near  the 
knee,  and,  when  the  joint  has  become  involved  and  the  cartilages  eroded,  in  many 
instances  the  degree  of  pain  felt  is  far  from  being  proportionate  to  the  gravity 
and  extent  of  the  destructive  process.  In  exceptional  cases  pain  may  be  excessive, 
and  may  be  felt  in  the  hip  as  well  as  the  knee,  or  may  be  referred  entirely  to  the 
acetabulum.  As  the  disease  progresses  the  swelling  increases,  and  is  due  not  only 
to  effusion  into  the  capsule,  but  also  to  thickening  of  the  ligaments,  and,  to  a 
certain  extent,  to  changes  in  the  ends  of  one  or  both  bones  which  enter  into  the 
formation  of  this  articulation.  Later  the  ligaments  give  way,  and  dislocation  of 
the  tibia  backward,  with  slight  outward  rotation,  occurs  (subluxation).  In  the 
earlier  stages  &f  the  ostitis  certain  constitutional  symptoms  appear,  and  remain 
throughout  the  course  of  the  disease. 

Treatment. — "Wlien  tubercular  arthritis  of  the  knee-joint  is  recognized  in  the 
early  stages,  the  indications  are  as  complete  rest  as  possible  for  tlie  joint  surfaces. 
This  can  be  obtained  in  a  moderate  degree  by  simple  fixation  with  plaster  of  Paris, 


Fig.  271. — Shaffer's  extension  knee  splint  for  knee-joint  disease  with  subluxation. 

but  this  does  not  give  the  degree  of  extension  which  is  essential  to  success.  If, 
however,  no  extension  apparatus  can  be  obtained,  the  leg  should  be  incased  in 
plaster  of  Paris,  closely  applied  while  extension  is  being  made,  from  the  level  of 


214 


THE   JOINTS— DISLOCATIONS 


the  perinasum  down  to  and  including  the  foot.  It  is  better  to  leave  the  knee  a 
little  short  of  full  extension — about  five  degrees  of  flexion.  ShafPer's  knee  splint 
or  brace  (Fig.  271)  is  capable  of  meeting  the  various  indications  of  extension, 
fixation,  and  rotation. 

A  simple,  less  costly,  and  very  efiicient  apparatus  is  Thomas'  knee  splint.  It 
consists  of  a  metal  ring  at  the  upper  or  perineal  end,  joining  two  parallel  bars  of 
iron,  the  ring  having  an  angle  of  about  forty-five 
degrees  to  the  inner  bar.  These  bars  jjroject  below 
(he  foot,  and  the  instrument  terminates  in  a  ring 
of  iron  (Fig.  372).  The  upj^er  or  thigh  ring  is 
well  padded  and  fits  closely  upon  its  inner  aspect 
against  the  porinaeum  and  tuberosity  of  the  ischium. 
It  is  fastened  to  the  leg  by  leather  straps  and  corset 
lacing  or  by  an  ordinary  roller-bandage.  A  shoul- 
der strap  or  suspender,  intended  to  hold  the  instru- 
ment against  the  perinseum,  passes  over  the  shoul- 
der of  the  side  opposite  to  that  of  the  disease.  A 
high  shoe  is  placed  upon  the  sound  foot,  and  the 
patient  walks  at  once  with  and  later  without  the 
aid  of  crutches,  the  weight  of  the  body  falling  upon 
the  perineeum  and  end  of  the  brace,  allowing  no 
concussion  in  the  knee-joint.  This  apparatus,  chiefly 
commendable  for  simplicity  and  cheapness,  does  not 
give  as  satisfactory  extension  as  the  Shaffer  splint. 
In  cases  of  knee-joint  disease  which  have  not 
received  proper  attention  in  the  earlier  stages  there 
will  very  frequently  be  found  a  condition  of  sub- 
luxation" of  the  tibia  (Figs.  271  and  273).  Exten- 
sion in  bed  in  two  directions,  as  shown  in  the  ac- 
companying cut,  will  have  to  be  made  until  the 
extremity  is  straight  enough  to  wear  either  the 
Shaffer  or  Thomas  splint. 

Operative  interference  at  the  knee-joint  should 
not  be  adopted  until  a  thorough  trial  has  been  made 
of  a  carefully  applied  and  well-attended  orthopfedic 
apparatus.  Sometimes  it  requires  three  or  four 
years  to  arrest  the  disease  and  effect  a  cure  by 
these  means,  but  it  is  often  accomplished  with  a  very  fair  degree  of  motion  left  in 
the  joint.  Operation,  when  it  becomes  necessary,  may  consist  of  incision  of  the 
capsule  and  drainage  when,  as  determined  by  high  temperature  and  great  pain 
and  constitutional  disturbance,  pyogenic  infection  has  taken  place,  or  excision  of 


Fig.  272. — Thomas'  knee  and  ankle 
brace. 


Fig.  273.— (After  Sayre.) 


the  joint.  Gouging  will  suffice  in  some  instances  where  the  destruction  of  bone  is 
limited,  but  generally,  when  forced  to  a  radical  step,  it  will  be  found  better  to 
make  a  clean  excision  of  the  parts,  according  to  the  rules  laid  down  for  excision 
^t  the  knee-joint. 


THE   JOINTS— DISLOCATIONS  215 

Charcot's  Disease. — The  knee-joint  (and  less  frequently  other  articulations)  is 
occasionally  the  seat  of  a  subacute  type  of  osteo-artliritis  which  is  in  all  proba- 
bility a  trophic  disturbance,  since  it  comes  as  a  prodroina  of  locomotor  ataxia 
(Charcot's  disease).  There  is  no  history  of  injury,  little  or  no  pain,  and  very  slight 
constitutional  disturbance.  The  knee  becomes  weak,  the  ligaments  relax,  and  there 
is  more  or  less  deformitj'-.  The  muscles  of  the  limb  become  atrophied,  and  finally 
there  is  a  disintegration  of  the  bone  substance. 

The  indications  in  treatment  are  to  protect  the  joint  by  a  brace  or  plaster  cast, 
and  later,  if  necessarj',  to  remove  the  offending  member  by  amputation. 

Wounds  of  the  knee-joint  do  not  require  special  consideration.  The  same  gen- 
eral principles  which  have  already  been  dealt  with  apply  to  this  joint,  which  on 
account  of  its  broad  surfaces  and  exposed  position  is  frequently  injured. 

Diseases  of  the  AnMc-joint. — The  pathology,  causes,  and  symptoms  of  disease 
at  the  ankle  do  not  differ  from  those  at  the  articulation  just  considered. 

Synovitis  is  oftener  traumatic  than  idiopathic.  The  exposed  position  of  this 
articulation,  which  is  called  upon  not  only  to  sustain  the  entire  body  weight,  but 
is  also  frequently  subjected  to  great  lateral  strain,  renders  it  exceedingly  liable 
to  injury. 

The  sjTnptoms  of  acute  traumatic  S3'novitis  at  the  ankle  are  usually  not  ob- 
scure. Swelling,  pain,  and  heat,  following  prolonged  or  violent  exertion,  a  twist, 
sprain,  or  other  injury,  bear  strong  evidence  of  inflammation  within  the  joint. 

The  injury  most  difficult  to  differentiate  from  intra-articular  synovitis,  and  one 
which  frequently  complicates  S3Tiovitis  here,  is  inflammation  of  the  sheaths  of  the 
tendons  which  play  around  the  joint.  The  evidence  of  thecitis  is  pain  in  the  track 
of  the  tendon,  either  elicited  hj  direct  pressure  or  by  placing  the  foot  slowly  in  a 
position  which  will  cause  the  greatest  tension  of  the  tendons,  and  then  requiring 
the  patient  to  move  the  foot  in  various  directions  which  are  resisted  by  the  oper- 
ator. To  test  the  peronei  muscles,  carry  the  foot  well  inward,  hold  it  firmly,  and 
ask  the  patient  to  turn  the  foot  out.  Thecitis  in  the  track  of  these  tendons  will 
arrest  the  effort  at  alxluction  and  outward  rotation.  The  reverse  of  this  manoauvre 
will  serve  to  demonstrate  a  similar  condition  in  the  flexors  and  internal  rotators. 

Tuberculous  synovitis  of  the  ankle-joint  is  less  painful  and  comes  on  slowly. 
Synovitis  from  exposure  to  cold,  gout,  or  rheumatism  is  frequently  sjTnmetrical, 
attacking  either  both  ankles  at  the  same  time,  or  first  one  and  then  the  other.  Trau- 
matic and  tuljerculous  synovitis,  on  the  other  hand,  are  almost  always  unilateral. 

The  prognosis  of  simple  synovitis  of  the  ankle,  when  proper,  vigorous,  and 
prompt  treatment  is  instituted,  is  in  general  favorable. 

Treatment. — Acute  synovitis,  whether  of  traumatic  or  idiopathic  origin,  de- 
mands rest,  with  an  elevated  position  of  the  foot.  Simple  cases  will  require  no 
more  than  this,  with  hot  or  cold  applications,  or  lead-and-opium  wash,  applied  by 
soft  cloths  laid  loosely  aroimd  the  ankle,  or  blotting  paper  kept  wet  with  vinegar. 
The  emplojTnent  of  compression  will  depend  upon  the  sense  of  relief  it  may  give 
the  patient.  Absorbent  cotton  or  soft  sponges  may  be  used,  applied  carefully  with 
a  flannel  or  muslin  roller. 

Aspiration  of  the  joint  to  relieve  extreme  tension  from  effusion  applies  here 
as  in  otlier  articulations.  The  needle  should  l)e  entered  in  front,  between  the 
anterior  margin  of  the  external  malleolus  and  the  contiguous  surface  of  the  tibia, 
away  from  the  vessels  and  nerves  which  are  opposite  the  middle  of  the  joint. 

-In  subacute  or  chronic  sjmovitis,  or  in  gonorrhoeal  arthritis,  compression  is  indi- 
cated, and  will  often  cause  absorption  of  the  excessive  effusion  in  the  joint.  It  is 
especially  demanded  after  aspiration,  to  give  support  to  the  parts  and  to  prevent  a 
further  effusion. 

Extension  is  indicated  when  its  employment  gives  relief  from  pain,  which  rest 
and  fixation  without  extension  do  not  afford.  Fixation  with  plaster-of-Paris  secures 
rest  to  the  joint  in  most  cases,  and  permits  of  locomotion  on  crutches. 

Arthritis  of  the  ankle  is  more  often  due  to  tuberculous  ostitis  of  the  tibia  or 
the  astragalus. 

The  symptovis  are  tliose  of  ostitis,  elsewhere  given,  and  the  diagnosis  and  prog- 
nosis do  not  differ  materially  from  similar  lesions  in  other  articulations, 


216  THE   JOINTS— DISLOCATIONS 

When  osteo-artliritis  with  i^yogenic  in-fection  is  evident,  operative  interference 
is  indicated,  for  the  reasons  that  (1)  early  incision,  by  giving  discharge  to  the 
contents  of  the  caiDSule,  retards  or  arrests  the  destructive  process;  (2)  tlie  common 
experience  of  surgeons  is  tliat  the  invasion  of  tliis  joint  is  practically  without  danger 
to  the  patient's  life. 

Complete  exsection  of  the  articular  ends  of  the  tibia  and  fibula,  and  of  the 
upper  half  of  the  astragalus,  is  rarely  called  for.  An  incision  upon  the  side  which, 
from  the  symptoms  jjresent,  will  give  the  best  access  to  the  diseased  bone,  and  the 
free  use  of  Volkmann's  s^joon  in  removing  the  dead  tissues,  will  usually  suffice. 
The  foot  should  be  kept  at  rest,  and  the  j^atient  directed  to  go  on  crutches  until 
several  months  after  the  discharge  has  ceased  and  the  sinus  closed.  The  operation 
of  gouging  is  more  successful  in  osteo-arthritis  at  the  ankle  than  in  any  other 
articulation.  Complete  exsection  is  only  admissible  when  the  destruction  is  very 
extensive. 

.Synovitis  and  osteo-arthritis  of  the  articulations  of  the  tarsus  and  metatarsus 
are  ticnIvMl   ii|iiin  the  same  general  principles  as  just  given  for  the  ankle. 

27/1'  ^liDiilder-joint. — Synovitis  of  the  shoulder  is  usually  general;  in  rare  in- 
stances it  may  be  local.  It  may  afliect  the  general  synovial  surface  of  the  cajjsule, 
be  reflected  into  the  synovial  sheath  of  the  long  head  of  the  biceps,  the  bursa  under 
the  tendon  of  the  subscapularis,  or  that  beneath  the  infra-spinatus,  or  in  rare 
instances,  especially  in  the  earlier  stages,  one  or  more  of  these  bursas  may  be  in- 
flamed, while  the  joint  is  not  invaded.  The  bursa  between  the  deltoid  and  the 
capsule  may  also  be  the  seat  of  bursitis,  although  this  sac  does  not  communicate 
with  the  joint.  The  diagnosis  of  inflammation  in  one  or  more  of  the  bursas  about 
the  shoulder  may  be  determined  as  follows:  1.  Direct  digital  pressure  upon  any 
single  bursa  will  indicate  the  sensibility  of  the  part.  2.  Extend  the  forearm  fully, 
grasp  tlie  hand  and  elbow  of  the  jiatient,  and,  while  the  head  of  the  humerus  is 
pulled  away  from  the  glenoid  cavity,  direct  the  patient  to  make  strong  flexion, 
which  the  operator  firmly  resists.  If  inflammation  of  the  sheath  of  the  long  head 
of  the  biceps  exists,  pain  will  be  experienced  in  the  anterior  and  outer  portion  of 
the  joint  as  this  tendon  is  made  tense.  3.  When  the  bursa  under  the  infra-spinatus 
is  inflajued,  if  the  arm  is  rotated  inward,  and  held  in  this  position,  pain  will  be 
felt  wlien  the  tendon  of  this  muscle  is  made  to  press  strongly  on  the  bursa,  in  any 
effort  at  outward  rotation. 

An  opposite  manoeuwe  will  serve  as  a  test  for  the  bursa  beneath  the  tendon  of 
the  subscapularis.  In  general  synovitis  each  of  these  movements  will  be  productive 
of  pain,  and  the  differentiation  is  chiefly  between  neuralgia  and  muscular  rlieu- 
matism.  In  neuralgia  jjain  is  rarely  constant,  the  exacerbations  appearing  at 
intervals  of  comparative  regularity,  and  extending  in  the  recognized  course  of  the 
nerves.  Motion  is  not  painful  in  the  degree  which  characterizes  either  synovitis 
or  rheumatism,  and,  if  persisted  in,  the  sense  of  pain  may  entirely  disappear. 
Swelling  is  not  a  feature  of  a  neurosis.  In  rheumatism  of  the  muscles  about  the 
joint  the  pain  is  superficial,  and  may  be  elicited  by  digital  pressure  upon  the  sub- 
stance of  the  muscles. 

Tlie  treatment  of  s^Tiovitis  is  the  same  at  all  joints.  Artificial  extension  is 
indicated  when  the  weight  of  the  extremity  is  not  .sufficient. 

Aspiration  is  a  safe  and  efficient  means  of  relief  from  pain,  and  is  indicated 
when  there  is  marked  capsular  tension.  The  needle  should  be  entered  through 
the  center  of  the  joint  in  front.  Fixation  of  the  joint  by  a  shoulder  cap  of  felt, 
cardboard,  or  leather,  should  be  secured  immediately  after  aspiration.  When  ready 
for  application,  lay  upon  the  surface  of  the  board  which  is  to  be  nearest  the  skin 
a  layer  of  absorbent  cotton,  which  shall  be  wide  enough  to  extend  entirely  around 
the  arm  and  over  the  shoulder,  place  it  in  position,  and  secure  snugly  by  a  flgure- 
of-8  Ijandage  around  the  arm  and  shoulder. 

Acute  suppurative  S3Tiovitis  demands  an  immediate  evacuation  of  the  purulent 
contents  of  tlie  capsule  by  incision  and  drainage.  The  line  of  incision  is  from 
the  anterior  internal  tip  of  the  acromion,  parallel  with  the  fibers  of  the  deltoid 
along  the  anterior  margin  of  the  great  tuberosity.  The  capsule  is  opened  external 
to  the  long  head  of  the  biceps,  and,  while  traction  is  firmly  made  upon  the  edges. 


THE   JOINTS— DISLOCATIONS 


217 


the  cavity  may  be  tliorouglily  explored  and  cleansed.  It  is  of  vital  importance 
that  in  this,  as  in  every  cavit}'  which  is  the  seat  of  purulent  inflammation,  drainage 
should,  when  possible,  be  established  from  that  portion  of  the  wound  which  is 
most  dependent.  As  the  patient  rests  in  bed  the  posterior  and  outer  part  of  the 
capsule  is  lowest.  A  drdl-pointed  dressing  forceps  should  be  carried  into  the  cap- 
sule through  the  anterior  incision  and  bored  through  the  inferior  posterior  wall 
and  all  the  tissues  to  the  skin,  and  when  this  is  pushed  ahead  of  the  instrument  an 
iacision  should  be  made  to  allow  the  escape  of  the  instrument.  The  wound  is 
stretched  hj  opening  the  jaws  of  the  instrument,  and  a  rubber  tube  puUed  into 
place  as  the  instrument  is  withdrawn.  In  tuberculous  osteo-arthritis  of  the  shoul- 
der-joint exsection  may  be  called  for,  after  all  conservative  measures  have  failed. 

The  Elbow-joint. — SjTiovitis  of  this  artictilation  need  not  be  separately  con- 
sidered. The  same  general  principles  of  diagnosis  and  treatment  apply  here  as  in 
other  joints.  Tuberculous  osteo-arthritis  demands  gouging  or  exsection  when  care- 
fid  corrective  mechanical  treatment  has  failed.     The  operation  will  be  given  hereafter. 

The  Wrist-joint. — Inflammation  of  the  s^Tiovial  membranes  of  the  wrist  or  in 
the  immediate  neighborhood  of  this  joint  is  of  frequent  occurrence.  It  is  often 
traumatic  in  origiti,  and  not  infrequently  tuberculous.  It  may  attack  the  synovial 
sac  between  the  ulna  and  radius:  that  between  the  radius  and  the  fibro-cartilage 
and  the  first  carpal  row ;  the  general  synovial  sac  between  the  first  and  second  rows 
and  the  metacarpus :  or  that  between  the  base  of  the  first  metacarpal  bone  and  the 
trapezius  (Fig.  2T4).  Inflammation  of  the  sheaths  of  the  tendons  on  the  dorsum 
of  the  carpus  or  on  the  palmar  surface  may  also  complicate  a  carpal  SATiovitis,  or 
exist  alone.  The  contiguity  of  these  various  structtrres  renders  a  positive  diagnosis 
of  great  difficulty.  If,  when  the  bones  of 
the  forearm  are  grasped  near  their  center 
and  pressed  together,  sharp  paia  is  elic- 
ited at  the  wrist,  sraovitis  of  the  radio- 
carpal sac  is  indicated.  'NMien  the  swell- 
ing is  well  defined  at  the  edge  of  the 
articular  end  of  the  radius,  extends  across 
the  wrist,  and  is  limited  to  the  situation 
of  the  first  row  of  the  carpus,  the  radio- 
carpal sac  is  probably  alone  involved. 
Wlien  the  several  capsules  are  involved 
the  swelling  is  general.  In  thecitis  the 
pain  is  superficial,  and  usually  extends 
for  some  distance  along  the  tendons  above 
and  below  the  joint.  Contraction  of  the 
muscles,  the  tendons  of  which  are  in- 
volved, will  point  to  the  location  of  the 
inflammation.  Differentiation  of  srao- 
vitis  from  Colles'  fracture  wiU  depend 
upon  a  sttidy  of  the  symptoms  of  this 
lesion  already  given.  Tuberculous  osteo- 
aiihritis  in  its  earlier  stages  is  comparatively  a  painless  process,  and  even  after 
the  capsule  is  invaded  is  rarely  as  painful  as  an  acute  sAmovitis. 

Treatment. — Synovitis  of  the  wrist  does  not  demand  separate  consideration. 
Destructive  osteo-artliritis  requires  gouging  rather  than  exsection.  Sraovitis  of  the 
metacarpal  or  interphalangeal  joints  should  be  treated  on  general  principles  of  rest 
and  fixation. 

EXSECTIOXS    OF    THE    JOIXTS 

The  Hip — Sayre's  Operation. — Place  the  patient  on  the  soimd  side;  carry  the 
point  of  a  strong  scalpel  perpendicularly  down  to  the  bone  exactly  half-way  between 
the  anterior  superior  spine  of  the  ilium  and  the  tip  of  the  trochanter  major ;  ^  cut 
along  the  neck  of  the  femur,  keeping  the  knife  firmly  in  contact  with  the  bone, 

1  The  extremity  should  be  held  parallel  with  the  axis  of  the  spine,  with  the  foot  normally  ro- 
tated outward. 


Fig.  274.— (-Aiter  Gray.) 


218 


THE   JOINTS— DISLOCATIONS 


carrying  the  incision  midway  between  tlie  center  and  posterior  aspect  of  the  tro- 
chanter, and  then  curving  it  slightly  forward  as  it  passes  about  an  inch  below  the 
tuberosity  (Fig.  275).  Through  this  incision,  which  divides  the  capsule  and 
thickened  periosteum,  insert  the  elevator  and  lift  the  periosteal  investment  from  the 
diseased  bone.  When  the  trochanters  are  involved,  the  tendons,  inserted  into  these 
eminences  and  into  the  dig-ital  fossa  just  above  the  great  tuberosity,  usually  require 
to  be  detached  with  the  knife,  the' point  of  which,  in  order  to  avoid  wounding  any 
vessels,  should  be  kept  in  close  contact  with  the  bone.  As  soon  as  the  periosteum  is 
freely  raised,  the  bone  should  be  divided,  with  the  author's  exsector,  the  Gigli  wire 

or  the  keyhole  or  metacarpal  saw,  and 
the  upper  fragment  lifted  out  with  the 


Fig.  276. — 1,  Ligamentum  tere.s.     2,  External  ob- 
turator muscles  and  obturator  vessels.     3,  Cir- 
ciunflex  vessels.     4,  Conjoined  tendon  of  psoas 
Fig.  275.  and  iliacus.     (After  Braune.) 

elevator.  The  sawed  surface  should  be  carefully  inspected  in  order  to  see  if  the  dis- 
ease extends  farther  down  the  bone,  necessitating  a  second  division.  The  acetabu- 
lum should  next  be  examined,  thoroughly  scraped  Avith  a  Volkmann's  spoon,  and 
all  dead  tissue  removed.  Hsemorrhage  is  usually  insignificant,  and,  if  occurring, 
should  be  arrested  as  the  operation  progresses.  The  wound  should  be  thoroughly 
irrigated  with  1-3000  sublimate,  all  shreds  of  tissue  and  particles  of  bone  re- 
moved, and  the  entire  cavity,  after  being  thoroughly  dried,  filled  with  sterile  gauze, 
well  packed  in,  and  held  in  place  by  a  thigh  and  pelvic  spica.  The  patient  should 
now  be  put  to  bed.  with  an  extension  apparatus  applied  as  given  for  the  early 
treatment  of  hip  disease.  Sand-bags  may  be  laid  along  the  leg  to  hold  the  foot 
in  the  proper  degree  of  outward  rotation,  or  a  splint  may  be  used.  The  long 
splint  from  the  axilla  to  the  heel  is  often  required  to  prevent  a  child  from  sitting 
upright  in  bed.  The  first  dressing  is  changed  usually  about  one  week  after  the 
operation,  and  once  or  twice  a  week  thereafter.  After  four  or  five  weeks  the 
case  should  be  treated  as  in  the  first  stage.  Profeissor  Sayre  prefers  the  Avire 
breeches  for  the  first  few  weeks  after  the  operation  (Fig.  270). 

In  a  certain  proportion  of  cases  the  disease  is  not  arrested  by  the  first  operation, 
and  a  second  is  required, 


THE   JOINT&— DISLOCATIONS 


219 


The  outline  of  the  parts  involved  in  this  operation  is  well  shown  in  Fig.  276. 

Excision  of  the  Knee-joint — Operation. — Under  rigid  asepsis  elevate  the  foot 
in  order  to  empty  the  extremity  of  blood,  and  after  a  minute  or  two  apply  the 
rubber  tourniquet  above  the  middle  of  the  thigh. 

With  the  leg  straightened  out,  or  slightly  flexed  (Fig.  277),  an  incision  is 
made  across  the  center  of  the  patella  and  down  on  each  side  until  the  level  of  the 
posterior  surface  of  the  tibia  is  reached. 
These  points  must  be  low  in  order  to 
secure  drainage.  The  skin  flaps  or  cufFs 
are  now  dissected  and  rolled  up  until 
the  upper  one  is  turned  back  about  three 
inches,  the  lower  two  inches.  As  the 
flaps  are  held  well  away  by  assistants, 
the   operator   cuts   down   to   the   femur 


Fig.  277. — Incision  for  exsection  of  the  knee. 


Fig.  278. — Showing  the  proper  line  for  sawing 
between  the  epipliyses  of  tlie  tibia  and  femur 
and  tlie  joint  cavity. 


through  the  tissues,  parallel  with  the  attached  edge  of  the  reflected  upper  flap, 
lifting  everything  from  the  anterior  aspect  of  the  femur  and  its  condyles  together 
with  the  patella,  the  attached  fringes,  ligamentum  patella,  and  coronary  ligaments 
• — thus  clearing  in  one  mass  all  the  tissues  which  envelop  the  anterior  three  fourths 
of  the  joint. 

By  sharply  bending  the  knee  the  crucial  ligaments  are  exposed  and  divided,  the 
lateral  ligaments  cut  away,  and  the  disarticulation  effected.  In  stripping  the 
attachments  of  the  ligamentum  posticum  Winslowii  from  the  tibia  and  femur,  the 
operator  shoiild  closely  hug  the  bone  and  thus  avoid  wounding  the  vessels.  This 
dissection  posteriorly  should  extend  about  three  fourths  of  an  inch  below  the  level 
of  the  tibia  and  one  and  a  half  inch  above  the  lowest  surface  of  the  condyles.  De- 
termining now  the  amount  of  bone  necessary  to  be  removed,  a  cloth  retractor^  is 
applied  so  as  to  protect  the  soft  parts  from  bone  detritus  or  injury,  and  a  slice 
thick  enough  to  freshen  the  head  of  the  tibia  is  sawed  away,  as  nearly  as  possible 
parallel  with  the  nornial  plane  of  the  articular  surfaces,  or  at  a  right  angle  to  the 


220 


THE  JOINTS— DISLOCATIONS 


perpendicular  axis  of  tliis  bone.  Should  the  section  expose  a  focus  of  disease  which 
dips  down  into  the  bone,  this  should  be  gouged  out  with  a  scoop  or  Volkmann's 
spoon,  and  finally  mopped  with  a  strong  bichloride  solution   (1-500).     It  is  im- 


Fie.  279. — Longitudinal  section   through   the  knee-joint.     1,   Peroneal   nerve.     2,  Popliteal  vessels. 

(After  Braune.) 


THE  JOINTS— DISLOCATIONS  221 

portant,  and  especially  in  children  and  young  adults,  that  the  section  should  not 
involve  the  epiphyseal  lines  (Fig.  378). 

The  section  through  the  end  of  the  femur  should  now  be  made  (Fig.  278). 
It  follows  that  if  the  limb  is  to  be  straight  in  the  position  of  ankylosis,  the  sawed 
surfaces  of  the  two  bones  must  be  parallel.  I  have  found  it  of  great  value  to 
employ  this  method.  By  pulling  on  the  foot  the  limb  is  fully  straightened,  and  the 
articular  surface  of  the  femur  separated  from  the  sawed  surface  of  the  tibia.  If 
the  operator  will  now  start  the  saw  into  the  femur,  sighting  by  the  flat  face  of  the 
tibia,  the  instrument  will  cut  directly  parallel  with  this.  If  by  error  the  section 
of  the  tibia  has  been  slightly  oblique,  that  of  the  femur  will  have  a  like  obliquity, 
and  therefore  the  bones  will  fit  snugly  with  the  extremity  straight. 

The  next  step  is  to  dissect  away  with  forceps  and  curved  blunt  scissors  all  the 
diseased  capsule.  This  should  be  done  thorouglily,  and  even  the  bursae  that  com- 
municate with  the  joint  should  be  cleaned  out.  If  care  is  not  taken,  a  portion  of 
the  sac  which  extends  up  beneath  the  quadriceps  tendon  will  not  be  removed.  All 
bleeding  points  should  be  tied  with  catgut  and  heemorrhage  stopped.  The  Ijones 
are  now  brought  in  exact  apposition,  and  while  so  held  the  steel  drills  (Fig.  214) 
are  introduced.  I  usually  carry  two  of  these  in  from  below  upward,  passing  them 
through  the  skin  about  two  inches  below  the  sa'wed  surface  of  the  tibia  and  directing 
them  obliquely  through  the  tibia  into  the  femur.  When  the  end  of  the  drill  has 
reached  the  compact  substance  of  the  femur,  it  is  stopped,  the  handle  unshipped, 
and  the  drill  left  in  position.  Three  are  used,  one  on  either  side  from  below,  and 
one  directly  down  the  median  line  from  above,  entering  the  femur  and  passing 
into  the  tibia. 

As  the  leg  is  now  held  steady  the  edges  of  the  incision  in  the  skin  are  sewed 
together  with  catgut  and  two  short  catgut  drains  inserted  at  the  lower  angles. 
Sterile  gauze  is  applied  and  one  thickness  of  absorbent  cotton  from  near  the  ankle 
to  the  crotch.  Over  this  successive  layers  of  veneering  on  thin  wooden  splints  are 
placed,  and  firmly  adjusted  to  the  leg  and  thigh  by  compression  with  a  bandage, 
the  whole  to  be  enclosed  with  a  light  plaster-of-Paris  cast.  This  dressing  is 
allowed  to  remain  on  for  six  weeks,  and  when  changed  the  drills  are  pulled  out. 
Should  it  for  any  reason  become  necessary  to  remove  it  about  the  fourth  week, 
the  pins  may  then  be  extracted.  The  indications  for  a  change  of  dressing  are 
haemorrhage,  high  temperature,  and  decomposition  of  the  discharge  beyond  the 
zone  of  asepsis. 

The  roller  should  be  firmly  dra'\\Ti,  so  that  a  considerable  pressure  may  be 
exercised  upon  the  parts  to  prevent  oozing.  The  elasticity  of  the  cotton  distributes 
the  pressure  equally,  and  controls  haemorrhage  without  causing  discomfort.  It 
is  the  practice  of  some  surgeons  not  to  apply  a  single  ligature  in  this  operation, 
but  to  rely  wholly  upon  compression  for  the  control  of  bleeding.  It  is  better 
to  search  for  and  tie  the  larger  vessels  which  may  have  been  divided.  Recovery, 
with  ankylosis  in  the  straight  position,  is  the  result  desired.  This  operation  has 
met  with  remarkable  success  within  late  years.  The  drills  are  preferable  to  nails 
in  fixation.  They  are  carried  into  position  by  steady  pressure  on  the  handle,  with 
a  slight  half-rotary  moveme^nt.  When  they  cannot  be  obtained,  the  parts  may  be 
held  in  apposition  by  wiring  or  by  nails. 

The  Ankle-joint. — For  the  complete  exsection  of  the  articular  ends  of  the 
tibia  and  fibula  and  the  astragalus,  proceed  as  follows:  Commence  an  incision 
on  the  internal  surface  of  the  tibia,  aljout  two  inches  above  the  tip  of  the  inner 
malleolus,  and  carry  it  directly  down  to  this  point,  and  thence  forward,  from  one 
inch  to  one  inch  and  a  half  along  the  tarsus,  in  the  direction  of  the  metatarsal  bone 
of  the  great  toe  (Fig.  280).  A  similar  L-shaped  incision  is  made  upon  the  filralar 
side  of  the  joint  (Fig.  281).  These  incisions  divide  all  the  tissues  down  to  the 
bone.  With  the  Sayre  elevator  lift  the  periosteum,  with-  its  attachments  to  the 
superjacent  soft  tissues  undisturbed,  from  the  diseased  portions  of  bone.  Expose 
the  outer  malleolus  and  fibula  as  high  as  it  is  deemed  necessary  to  remove  this 
bone,  and  divide  it  with  the  exsector  (^or  chisel).  As  soon  as  the  piece  is  removed 
the  joint  is  tlioroughly  exposed  to  view.  Now,  further  lift  the  periosteum  of  the 
tibia  and  tarsus,  and,  by  forcibly  bending  the  foot  inward,  dislocate  the  tibia  and 


222 


THE  JOINTS— DISLOCATION^ 


inner  malleolus  outward,  through  the  wound  on  the  fibular  side.  The  diseased 
surface  may  be  sawn  off  with  an  ordinary  saw,  or  with  the  exseetor.  The  section 
through  the  astragalus  may  be  made  with  a  gouge,  chisel,  or  a  keyhole  saw.     Usu- 


ally no  vessels  of  importance  are  wounded  in  this  dissection,  since,  by  keeping 
beneath  the  periosteum,  they  are  lifted  with  the  tissues.  The  periosteum  should 
not  be  elevated  over  the  healthy  bone.  The  sawed  surfaces  are  now  brought  in 
apposition,  so  that  the  foot  will  be  at  an  angle  of  ninety  degrees  with  the  axis 
of  the  leg.  Fixation  may  be  secured  by  transfixion  with  small  steel  drills,  carried 
obliquely  from  above  downward,  entering  on  the  internal  aspect  of  the  tibia  and 
the  external  surface  of  the  fibula,  and  passing  into  the  astragalus  (in  the  same 
manner  as  at  the  knee) .  The  wound  should  be  closed  with  catgut,  leaving  a  small 
catgut  drain  to  jjass  out  on  each  side.  An  aseptic  dressing  should  be  applied,  and 
over  this  plaster  of  Paris. 

If  the  drills  are  not  employed,  the  parts  should  be  held  in  apposition  while  a 
plaster- of -Paris  dressing  is  applied.     Or  a  Volkmann's  splint   (Fig.  283)   may  be 


Fig.  282. — Volkmanu's  anterior  splint. 


applied  to  the  anterior  extremity  of  the  foot  and  leg,  and  the  parts  fixed  with 
plaster  of  Paris,  or  simple  roller.  This  splint  may  be  made  of  wood,  or  sheet  or 
hoop  iron,  j^roperly  padded  with  sterile  gauze. 

If  the  l3ones  are  not  extensively  involved,  a  single  L-shaped  incision  will  suffice 
to  expose  the  joint,  and  the  dead  bone  can  be  removed  with  the  gouge  or  Volk- 
mann's spoon  and  a  counter-opening  made  for  drainage.  This  operation  is  always 
to  be  preferred  at  the  ankle. 

When,  in  an  exsection  of  the  ankle,  the  astragakis  is  so  much  involved  that  its 
removal  is  necessary,  the  upjjer  surface  of  the  os  calcis  should  be  smoothed  off  with 
the  chisel  or  keyhole  saw,  and  brought  up  in  apposition  with  the  plane  surface  of 
the  bones  of  the  leg. 

The  Shoulder-joint. — Exsection  of  the  head  of  the  humerus  is  readily  effected 
by  a  single  straight  incision,  about  five  inclies  in  length,  made  from  the  acromion 
process  directly  down  the  arm,  parallel  with  and  S]5litting  the  fibers  of  the  deltoid 
(Fig.  284).    The  periosteum  should  be  carefully  lifted  as  far  as  the  ostitis  extends, 


THE  JOIXTS— DISLOCATIONS 


223 


and  the  soft  tissues  about  the  capsule  raised  -n-ith  the  elevator.  The  edges  of  the 
wound  should  be  held  wide  apart  by  blunt  retractors,  and  the  tendons  of  insertion 
of  the  supra-  and  infra-sjiinatus,  teres  minor,  and  subscapularis  divided  close  to 
the  tuberosities  with  the  curved  blunt  scissors.  The  sheath  for  the  long  head  of 
the  biceps  should  be  laid  open,  and  this  tendon  held  aside.  The  bone  should  now 
be  divided  at  the  limit  of  the  disease.  When  the  section  is  completed  a  strong 
hook  should  be  fastened  into  the  end  of  the  upper  fragment,  in  order  to  lift  it  and 


.3  e 


o    _ 


facilitate  the  separation  of  the  soft  tissues  on  the  inner  and  under  surface  from 
the  bone  and  capsule.  The  capsular  ligament  should  be  trimmed  from  the  mar- 
gins of  the  glenoid  cavity  and  removed  with  the  head  of  the  humerus.  All  diseased 
tissues  should  be  dissected  out  with  the  curved  scissors,  and,  if  the  head  of  the 
scapula  is  involved,  all  disorganized  bone  should  be  scraped  away  with  the  spoon 
or  rongeur.    The  capsule  should  now  be  divided  and  the  head  of  the  bone  dislocated 


224 


THE  JOINTS— DISLOCATIONS 


upward  through  the  wound.  The  division  is  then  made  with  a  narrow  saw,  taking 
the  precaution  to  protect  the  soft  parts  from  injury.  Upon  examining  the  wound 
left  after  this  operation,  it  will  be  seen  that  the  deepest  portion  is  behind  and  to 
the  outer  side  of  the  end  of  the  shaft.  Into  this  depression  carry  a  closed  dressing 
forceps,  and  bore  through  to  the  skin,  pointing  the  instrument  to  the  inferior  and 
outer  aspect  of  the  arm.  Divide  the  skin  over  the  point  of  the  forceps,  dilate  the 
opening  by  separation  of  the  handles,  and  draw  a  catgut  drain  from  below  up- 
ward through  the  hole.  A  second  shorter  one  should  make  its  exit  through  the 
anterior  and  lower  angle  of  the  incision,  and  the  wound  closed  throughout  with 
catgut.  The  forearm  should  be  held  in  a  sling  or  fastened  across  the  abdomen. 
The  application  of  Esmarch's  bandage,  and,  the  rubber  tubing  in  the  axilla  and  over 
the  clavicle  and  scapula,  renders  this  operation  practically  bloodless.  The  rate  of 
mortality  is  exceedingly  low. 


Fig.  285. — Longitudinal  section  through  the  slioulder-joint, 
showing  the  relations  of  the  bones,  ligaments,  and  muscles 
immediately  about  the  articulation.  1,  The  capsular  liga- 
ment.   2,  The  acromion.     3,  Epiphysis.      (After  Braune.) 


Tlia  ETboiv-joint. — Flex  the  forearm  on  the  arm  and  make  a  straight  incision, 
commencing  in  the  middle  of  the  posterior  asjaect  of  the  humerus^,  about  one  inch 
above  the  condyles,  and  extending  over  the  center  of  the  olecranon  process,  along 
the  ulna  for  from  two  to  three  inches  (Fig.  286).  The  tissues  should  be  care- 
fully lifted  from  the  bone  and  capsule,  and  held  to  either  side  by  blunt  retractors. 
When  the  trough  between  the  olecranon  and  internal  condyle  is  approached,  extra 
care  should  be  taken  not  to  wound  the  ulnar  nerve,  which  passes  in  this  groove. 
It  may  be  avoided  by  keeping  close  to  the  bones  with  the  knife  or  elevator.  The 
articular  end  of  the  himierus  should  be  exposed,  as  high  as  the  point  of  section,  by 
peeling  off  the  soft  tissues  with  the  periosteum,  after  which  a  retractor  is  applied 
and  the  bone  divided  at  an  angle  of  ninety  degrees  to  the  shaft  of  the  humerus. 
The  ends  of  the  ulna  and  radius  may  now  be  readily  displaced  backward,  exposed  to 
the  point  of  section,  and  divided  on  a  line  parallel  with  that  through  the  humerus. 
As  in  all  the  joint  exsections,  a  careful  dissection  of  all  the  diseased  capsule  and 
soft  parts  must  be  made.  The  wound  is  drained  from  the  most  dependent  portion 
by  means  of  catgut,  and  closed  with  sutures  of  the  same  material.  An  anterior 
splint,  previously  fitted  to  the  arm  and  forearm,  and  fashioned  so  as  to  hold  the 
forearm  half-way  between  flexion  at  a  tight  angle  and  complete   extension,   is 


THE   JOINTS— DISLOCATIOXS 


225 


wrapped  with  gauze  and  laid  on  the  anterior  aspect  of  the  extremity,  and  fixed 
by  a  roller  to  the  arm  and  forearm,  to  within  a  few  inches  of  the  incision.  A 
sterile  dressing  is  next  apj^lied  to  the  wound,  with  cotton  and  protective,  and  a 
bandage  over  this  to  effect  compression  and  to  hold  it  in  position.  When  a  change 
of  dressing  is  required,  this  last  bandage  only  is  removed.  After  tlie  sixth  week 
passive  motion  should  be  commenced,  and  should  this  not  produce  a  too  painful 
inflammatory  reaction  it  should  be  repeated  once  or  twice  a  week  for  two  or  three 
montlis.  Ansesthesia  is  essential.  A  very  considerable  degree  of  mobility  may  be 
gained  by  this  practice,  although  the  rule  in  this  exsection  is  fibrous  ankylosis,  with 
limited  motion  of  the  joint  and  function  of  the  extremity. 

Exsection  of  the  elbow  is  not  a  dangerous  jjrocedure,  and,  although  not  usually 
attended  with  the  success  which  follows  some  other  operations  (as  those  upon  the 


jitudinal  section  through  the  elbow-joint.      1,  Radial  nerve.     Superficially  on  the  flexor 
surface  the  median  basilic  vein  is  seen  cut  across.   .  (After  Braune.) 


shoulder  and  ankle),  it  should  be  preferred  to  amputation.  The  anatomical  rela- 
tions at  this  joint  are  shown  in  Fig.  287. 

The  Wrist-joint. — The  exsection  of  this  joint  is  attended  with  considerable 
difficulty,  not  only  ia  the  performance  of  the  operation,  but  in  the  after-treatment. 
Of  the  two  procedures — viz.,  the  double  lateral  and  parallel  incisions  {Fig.  288) 
and  the  single  longitudinal  dorsal  incision  (Fig.  289) — the  latter  is  preferable 
when  the  destructive  jjrocess  is  not  so  extensive,  and  when  the  spoon  or  gouge  may 
be  used,  while  the  former  will  give  the  freest  access  to  the  bones  when  the  saw  or 
exsector  is  to  be  emplo^'ed  in  the  removal  of  a  large  portion  of  the  bones  which 
enter  into  the  composition  of  this  joint. 

In  the  operation  with  a  single  dorsal  incision  the  wiist  should  be  made  promi- 
nent, by  flexing  the  hand  on  the  forearm,  and  the  integument  divided  along  the 
■tendon  of  the  extensor  communis  digitorum,  which  goes  to  the  index-finger,  the 
incision  extending  from  the  middle  of  the  metacarpus  to  one  inch  and  a  half 
above  the  tip  of  the  styloid  processes.  The  tendon  may  be  retracted  to  the  side 
most  convenient.  The  posterior  segment  of  the  annular  ligament  is  divided,  and 
the  tissues  lifted  from  the  bones  with  the  elevator.  The  end  of  the  radius  should 
be  removed  with  the  exsector  or  gouge,  when  the  carpus  may  be  displaced  backward 
through  the  incision,  and  removed  wholly  or  in  pieces.  When  the  section  is  com- 
pleted, the  surfaces  should  be  brought  in  apposition  and  fixed  upon  a  well-adjusted 
anterior  splint.  Or  an  interrupted  dressing  may  be  applied  by  incasing  the  forearm 
in  plaster  of  Paris  to  within  an  inch  of  the  incision,  and  the  fingers  and  hand  in 
the  same  material,  back  as  far  as  the  anterior  limit  of  the  wound.     A  piece  of 


226 


THE  JOINTS— DISLOCATIONS 


hoop  iron  (or  several  pieces  of  telegraph  wire  twisted  into  a  single  piece)  is  shaped 
as  shown  in  Fig.  290,  incorporated  into  the  plaster  upon  the  arm,  and  made  to 
loop  over  the  wrist  to  the  tips  of 
the  fingers,  where  it  is  turned  back 


Fig.  288. — Bourgery's  operation 
(modified). 


Fig.  289. — Langenbeclc's  incision. 
(After  Esmarcli.) 


underneath  the  hand,  and  is  fastened  to  the  plaster  here  bv  an  additional  gypsum 
bandage  (Fig.  291). 


Fig.  291. — Tlie  same  applied. 


In  the  other  operation  one  incision  is  made  along  the  outer  and  dorsal  aspect 
of  the  metacarpal  bone  of  the  little  finger,  over  the  styloid  of  the  ulna,  and  one 


THE   JOIXTS— DISLOCATIONS 


inch  along  this  bone.  The  radial  incision  should  commence  on  the  dorsum  of  the 
metacarpal  bone  of  the  index-finger,  pass  backward  and  slightly  toward  the  radial 
surface  of  the  forearm  to  a  point  half  an  inch  above  the  tip  of  the  styloid  process, 
and  thence  directly  upward  along  the  dorsal  aspect  of  the  radius.  In  extensive 
operations  it  may  become  necessary  to  divide 
the  tendon  of  the  extensor  ossis  metacarpi 
pollicis,  which  is  crossed  by  the  incision. 
When  done,  the  ends  should  be  reunited  by 
silk  sutures  when  the  operation  is  finished.- 
The  tissues  are  lifted  from  the  bones  .  and 
capsule  as  before,  and  the  sections  made  -ivith 
the  exsector  or  keyhole  saw. 

Metacarpo-phalangcal  and  Inter-plialan- 
gcal  Joints. — Excision  of  the  metacarpo-pha- 
langeal,  on  the  inter-phalangeal  articulations, 
may  be  done  when  the  destruction  of  bone  is 
limited.  The  same  general  rule,  viz.,  that  an 
excision  is  preferable  to  amputation,  is  ap- 
plicable both' to  the  hand  and  foot.  At  the 
terminal  joints,  however,  the  small  size  of  the 
last  phalanges  will  rarely  permit  of  any  oper- 
ation except  amputation. 

Muscles  and  Tendons. — Of  the  diseases 
which  affect  the  tendons  or  their  sheaths  and 
which  require  surgical  interference,  tubercu- 
losis is  bj'  far  the  most  important.  It  may 
affect  any  tendon  of  the  body,  but  is  chiefly 
met  with  in  the  sheaths  on  the  dorsum  of  the 
wrist.  The  s}Tuptoms  are  usually  those  of 
swelling,  which  gives  a  puffy  appearance  to 
the  entire  back  of  the  hand.  Pain,  although 
at  times  severe,  is  not  a  constant  symptom. 
The  only  operative  procedure  which  promises 
success  is  that  which  exposes  the  tendons  in- 
volved by  an  incision,  usuall}^  longitudinal, 
and  a  thorough  dissection  of  the  sheath  from 
the  tendon.  The  use  of  an  Esmarch  Ijandage 
facilitates  the  operation.  Most  careful  asepsis 
should  be  practiced,  the  woimd  closed,  and 
the  patient  should  be  directed  to  move  the 
fingers  while  the  process  of  repair  is  going 
on,  in  order  to  prevent  adhesions  of  the  ten- 
don to  the  integument  or  bone. 

In  rupture  or  division  of  tendons  it  is 
essential  to  itnite  these  at  once  by  operation. 
Two  sutures  of  fine  silk  are  passed  entirely 
through  the  substance  of  the  tendon,  about 
one  eighth  of  an  inch  from  the  end,  then 
tied  and  left  in  position. 

Rupture  of  the  tendon  of  the  quadriceps 
extensor  fenioris  is  the  most  important  in- 
jury connected  with  tendons. 

The  rational  treatment  and  the  only  one 
that  appears  to  offer  any  hope  of  success  with 
restored  function,  is  to  expose  the  seat  of 
rupture  under  the  most  careful  asepsis  and  reunite  the  ends  by  direct  suture.  Silk 
is  the  best  material  to  employ.  When  a  sufficient  fragment  of  tendon  has  been 
left  attached  to  the  patella,  the  sutures  should  be  passed  through  this.  When 
rupture  has  taken  place  close  to  the  bone,  two  holes  should  be  drilled  in  the  upper 


Fig.  292. — Longitudinal  section  through 
the  forearm,  wrist,  and  hand.  (After 
Braune.) 


228  THE  JOINTS— DISLOCATIONS 

segment  of  the  bone,  as  practiced  by  Buchanan,  of  Pittsburg,  and  the  tendon  of 
the  muscle  iirmly  united  to  this  by  a  double  set  of  silk  sutures.  The  sooner  the 
operation  is  done  after  the  injury,  the  better.  The  limlj  should  be  immobilized 
in  full  extension  after  the  operation. 

Wien  the  ligamentuin  patellce  is  torn,  suture  should  be  attempted,  as  for  the 
quadriceps  tendon.    The  prognosis  is  even  more  unfavorable. 

In  certain  forms  of  paralysis,  especially  of  the  muscles  wliich  move-  the  fingers, 
liands,  and  feet,  it  may  at  times  be  required  to  transpose  a  portion  of  the  tendon 
of  a  non-paralyzed  muscle  and  unite  it  to  the  tendon  of  one  which  has  lost  its 
function,  the  method  of  Dr.  B.  F.  Parrish  (New  York  Medical  Journal,  October  8, 
1892).  The  tendon,  or  one  half  of  the  tendon,  of  a  live  muscle  is  in  this  operation 
sutured  to  the  divided  tendon  of  a  dead  or  paralyzed  muscle.  Whether  the  union 
shall  be  end  to  end  or  lateral  (overlapping)  must  be  determined  by  the  conditions 
to  be  corrected. 

Elongation  of  the  tendons  of  contracted  or  shortened  muscles  may  also  be 
efl'ected  by  partial  division  on  opposing  surfaces  at  a  given^distance,  splitting  the 
intervening  portion  and  uniting  the  half  ends  by  suture. 

Tlie  reunion  of  torn  or  incised  muscles  sliould  be  effected  liy  immediate  suture 
with  linen,  silk,  or  kangaroo  tendon.  The  sutures  must  of  necessity  take  hold  in 
the  slieaths,  aponeuroses,  or  other  dense  connective  tissue,  as  the  fasciculi  pi-oper 
are  too  friable  to  resist  tension.  After  suture  the  position  must  be  selected  which 
will  reduce  the  tension  to  the  minimum. 


CHAPTEE    XI 

THE    SCALP SKULL BRAIN CRANIAL    NERVES,    SPINAL    CORD    AND     NERVES 

Tumors  of  the  Scalp. — Tumors  of  the  scalp  are  congenital  and  acquired. 

Congenital  cysts  are  deei^ly  situated,  being  beneath  the  skin,  and  not  infre- 
quently below  the  fascia  and  muscles.  Their  contents  are  chiefly  white  or  yellow 
fluid,  and  at  times  hairs  {dermoids).  Each  tumor  may  consist  of  a  single  cyst, 
or  there  may  be  several  groui^ed  together  (multilocular),  the  mass  rarely  attaining 
a  size  greater  than  an  inch  in  diameter. 

If  left  alone  they  may  ulcerate  from  pressure  or  injury,  or,  in  rare  instances, 
may  cause  atrophy  and  perforation  of  the  calvaria  and  dura  mater.  They  should 
be  removed  in  early  childhood.  The  operation  consists  in  dissecting  out  the  sac, 
with  its  contents.  As  a  rule,  small  wounds  of  the  scalp,  situated  where  a  scar  will 
not  be  apparent,  do  not  need  to  be  stitched.  The  edges  should  be  approximated 
and  held  thus  hj  a  dressing  of  sterile  gauze  and  a  bandage. 

Acquired  cysts,  commonly  called  "wens,"  are  of  two  varieties,  one  due  to  reten- 
tion of  sebum  in  a  sebaceous  follicle,  the  duct  of  which  has  been  olistructed :  the 
other  caused  b)'  extravasation  of  blood,  where  the  clot  has  been  ab5orl)ed,  leaving 
the  serum  more  or  less  stained  by  the  decomposition  of  ha?matin.  Thev  are  round, 
smooth  tumors,  are  superficial,  and  found  most  frequently  upon  tlie  upper  and 
posterior  portion  of  the  scalp.  They  are  mostly  multiple,  are  unilocular,  and  con- 
tain a  granular,  cheesy  substance.  The  treatment  is  removal  with  the  knife.  The 
hair  should  be  shaved  from  the  tumor,  and  for  a  slight  distance  beyond  its  base. 
Complete  anaesthesia  can  l^e  obtained  by  cocaine  infiltration.  With  a  sharp  bis- 
toury transfix  the  mass  through  its  l^ase,  and  lay  it  open.  The  integument  over  the 
center  of  the  tumor  will  be  found  exceedingly  thin  (not  thicker  than  ordinary 
writing  paper),  and  may  be  easily  separated  from  the  thickened  sac,  which  should 
now  be  seized  with  a  strong  pair  of  forceps  and  torn  out  of  its  bed.  If  any  strong 
adliesions  are  found  they  should  be  divided  with  the  blunt  scissors. 

Sebaceous  cysts  occasionally  become  inflamed,  the  capsule  breaks  down,  the 
contents  escape,  and  a  mass  of  granulation  tissue  rej)laces  the  original  tumor.  The 
new-formed  capillaries  in  this  tissue  frequently  give  way,  causing  repeated  htemor- 
rhage.  They  should  be  scraped  out  with  a  sharp  spoon,  and  the  sac  removed  by 
dissection. 

Horns,  or  dense  epithelial  outgrowths,  are  occasionally  seen  upon  the  scalp  and 
face.  Some  of  these  excrescences  attain  large  size.  The)'  should  be  removed  by 
an  elliptical  incision  through  the  entire  thickness  of  the  integument. 

Lipomata  are  of  infrequent  occurrence  beneath  the  scalp,  and,  on  account  of 
the  dense  integument,  they  grow  very  slowly  and  rarely  attain  large  size.  The 
diagnosis  between  sebaceous  and  fatty  tumors  of  this  region  is  not  always  easy. 
The  treatment  is  removal  by  dissection,  which  is  easily  effected  by  lifting  the  tumor 
from  its  capsule  with  the  finger  or  the  blunt  scissors.  The  capsule  need  not  be 
removed. 

Nwvi,  port-ivtne  marls,  and  other  vascular  tumors,  are  quite  common  upon  the 
scalp.    They  have  been  considered  in  a  previous  chapter. 

Papillomata,  or  ivarts,  occasionally  covering  a  large  area,  are  found  in  this 
region.  They  should  be  clipped  closely  with  the  curved  scissors,  their  bases  burned 
with  the  actual  cautery  or  nitric  acid,  and  the  operation  repeated  until  a  cure  is 
efEected. 

229 


230     SCALP— SKULI^-BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES 

Ulcers  from  sypliilUic  gumma  of  the  skull  are  quite  frequently  met  with  in 
the  scalp. 

Tuberculosis  (lupus)  of  the  skin  is  rare  in  this  region. 

Elephantiasis,  or  general  thickening  of  the  scalp  from  connective-tissue  new 
formation,  is,  fortunately,  rarely  met  with.  Ligation  of  the  vessels  feeding  the 
diseased  area  will  afEord  temjjorary  relief,  and  may  be  followed  by  p)artial  or  com- 
plete extirpation. 

Hwmatoma  has  been  considered  in  the  chapter  on  Wounds  of  the  Scalp. 

Abscess  of  the  scalp  requires  free  incision,  irrigation,  and  drainage.  Any  doubts 
as  to  the  character  of  the  swelling  may  be  dissipated  by  exploration  with  the  hypo- 
dermic syringe  and  a  good-sized  needle. 

Pneumatocele,  or  "  air  tumor,"  is  occasionally  met  with  beneath  the  scalp.  It 
results  from  disease  or  fracture  of  some  of  the  bones,  permitting  communication 
with  the  cavities,  as  the  frontal  sinus,  or  the  Eustachian  tube,  etc.,  and  the  escape 
of  air  beneath  the  skin.  Evacuation  of  the  contents  by  pressure,  with  "or  without 
puncture,  and  a  compress  to  jjrevent  recurrence,  will  produce  inflammatory  adhe- 
sions and  effect  a  cure.  -'' 

Ostitis,  or  periostitis,  is  not  uncommon  in  the  calvaria.  The  causes  are  the 
same  as  for  ostitis  elsewhere.  Great  care  should  be  observed  in  the  treatment,  on 
account  of  the  proximity  of  the  meninges  and  brain.  Ostitis  with  exfoliation  de- 
mands early  recognition  and  immediate  operative  interference.  The  rubber  tour- 
niquet around  the  skull  may  be  employed  to  control  bleeding.  A  free  horseshoe  or 
crucial  incision  should  be  made,  and  all  the  diseased  bone  removed  with  the  sharp 
spoon.  AYhen  the  exfoliation  is  confined  to  the  outer  taljle  of  the  skull  the  prog- 
nosis is  favorable.  The  wound  should  be  kept  open,  well  drained,  and  allowed  to 
heal  by  granulation.  If  pus  is  found  beneath  the  inner  table,  enough  of  the  bone 
should  be  cut  away  with  the  rongeur  to  permit  the  free  escape  of  all  the  products 
of  inflammation.  The  patient  should  be  required  to  rest  in  the  position  which 
secures  most  perfect  drainage.    A  loose  aseptic  dressing  should  be  applied. 

Abscess  of  the  Froiital  Sinuses. — Chronic  inflammation  of  these  sinuses  de- 
mands, as  a  rule,  energetic  and  thorough  operative  measures.  The  accumulation 
of  pus  may  interfere  with  the  integrity  of  the  eye,  often  breaking  out  through  the 
orbit.  Headaclie,  great  discomfort,  and  frequent  and  dangerously  high  temper- 
atures indicate  the  sepsis  which  is  occurring. 

Operation. — Shave  the  eyebrow  of  the  afliected  side  and  make  an  incision  through 
the  middle  line  of  the  brow  so  that  when  the  hairs  grow  out  the  scar  will  be  con- 
cealed. The  incision  should  be  free,  extending  across  the  root  of  the  nose,  if 
necessary.  When  the  bone  is  exposed,  the  sinus  is  entered  by  chiseling  with  a 
small  curved  instrument  through  the  anterior  lamella  of  the  frontal  bone  at  the 
inner  angle  of  the  supra-orbital  arch.  A  light  mallet  should  be  employed  and  the 
chisel  should  be  held  with  the  point  directed  toward  the  root  of  the  nose,  so  that 
a  slip  would  not  injure  the  eye  or  brain.  Continuing  into  the  sinus,  an  opening 
one  fourth  of  an  inch  in  diameter  should  be  made  and  the  walls  of  the  cavity 
thoroughly  scraped  with  the  sharp  spoon. 

A  strong  dressing  forceps  should  now  be  carried  into  this  opening,  against  the 
upper  turbinated  bones,  and  made,  by  boring,  to  crush  through  into  the  nasal 
cavity.  A  probe  is  next  carried  throiigh  this  hole  and  brought  out  at  the  nostril 
of  the  affected  side,  and  by  this  a  strong  silk  thread  is  carried  through.  A  good- 
sized  piece  of  gauze — so  twisted  that  while  the  end  is  as  small  as  a  cord  the  middle 
portion  is  as  large  as  the  little  finger— is  tied  to  the  string  and  drawn  through  the 
sinus  into  the  nasal  cavity  and  out  at  the  nostril.  The  entire  twist  of  gauze  is  now 
pulled  through.  This  breaks  away  the  turbinated  bones,  does  not  cause  annoying 
haemorrhage,  and  leaves  perfectly  free  drainage  into  the  nose  and  mouth. 

The  edges  of  the  wound  should  be  united  with  fine  silk  sutures.  In  cases  where 
the  disease  is  unusually  extensive  and  the  discharge  profuse,  it  will  be  advisable 
to  carry  a  small  soft-rubber  drainage  tube  in  through  tlie  wound  down  into  the 
nose,  leaving  one  end  projecting  through  the  nostril  and  the  other  at  the  inner 
angle  of  the  incision  above.  For  one  or  two  weeks  after  the  operation  irrigation 
through  the  tube  with  warm  salt  solution  should  be  practiced  once  a  day.     When 


SCALP— SKULL— BRAL\—CR.\XIAL    NERVES,    SPIXAL    CORD    .\ND    XERVES     231 

the  tube  is  removed  it  should  be  drawn  out  through  the  nose.  If  both  sLauses 
are  involved,  an  incision  on  one  side  may  suiBce  bj'  breaking  down  the  shell  of  bone 
which  intervenes,  and  curetting  the  opposite  sinus  with  the  sharp  spoon. 

The  effort  to  cure  abscess  of  the  frontal  sinus  by  incision  and  drainage  at  the 
angle  of  the  orbit  is  not  only  apt  to  fail,  but  it  endangers  the  integrity  of  the  eye. 

Osteoma,  or  exostosis,  occurs  quite  frequently  upon  the  bones  of  the  skull. 
When  not  due  to  sj'philis  it  should  be  removed  early,  by  the  gouge  or  chisel,  as 
there  is  always  danger  of  pressure  upon  important  organs  if  allowed  to  remain. 
Syphilitic  hyperostosis  requires  the  specific  treatment  given  for  tliis  dyscrasia  be- 
fore resorting  to  operation. 

Eiicephalocele,  or  hernia  cerebri,  is  a  protrusion  of  the  brain  substance  through 
an  opening  in  the  calvaria.  This  condition  usually  occurs  in  children  suffering 
from  hydrocephalus,  the  protrusion  taking  place  through  the  abnormally  enlarged 
fontaneUes.  The  dura  mater  surrounds  and  is  carried  in  front  of  the  mass,  lying 
in  contact  with  the  pericranium.  When  the  meninges  alone  protrude,  the  tumor 
is  known  as  a  meningocele.  Wliile  this  variety  of  tumor  may  occur  at  any  point 
in  the  line  of  sutures,  a  favorite  seat  is  in  the  median  line  of  the  skull,  below  the 
occipital  protuberance.  It  may  be  covered  with  integument,  or,  as  with  certain 
forms  of  spina  bifida,  the  meninges  form  the  outer  covering. 

Meningocele  is  often  incurable.  Careful  compression  may  limit  the  further 
development  of  the  tumor,  and  in  rare  instances  the  opening  in  the  skull  closes 
spontaneously  and  a  cure  results.  Wlien  the  mass  is  covered  with  integument  and 
the  pedicle  small,  a  rubber  ligature  gradually  tightened  is  advisable. 

Hernia  cerebri  may  occur  after  perforation  of  the  slaill  from  any  cause,  as 
fracture  or  necrosis.  More  frequently  the  mass  which  protrudes  is  made  up  of  a 
granulation  tissue  containing  no  elements  from  the  brain  substance,  while  at  times 
these  masses  are  composed  of  both  brain  and  granulation  tissue.  The  character 
of  the  tumor  will  be  recognized  from  its  rapid  development  after  perforation  of 
the  calvaria.  ^ 

Treatment. — When  the  mass  is  small,  and  is  just  begiiming  to  project,  com- 
pression should  be  employed  to  prevent  a  further  protrusion.  It  is  not  safe  to 
attempt  a  reduction  of  the  tumor.  The  hair  should  be  shaved  from  the  scalp  near 
the  opening  and  disinfection  accomplished  by  sublimate  irrigation,  and  a  compress 
of  sterile  gauze  and  absorbent  cotton  applied.  If  the  tumor  does  not  rapidly  slough 
away,  it  should  be  removed  at  the  level  of  the  scalp  with  the  elastic  ligature  or 
the  actual  cautery. 

Sarcoma  of  the  dura  mater  is  a  grave  condition,  fortunately  of  infrequent  occur- 
rence. In  the  process  of  development  the  tumor  is  apt  to  cause  absorption  of  the 
calvaria,  and  finally  perforation.  This  usually  occurs  long  after  sjmiptoms  of  pres- 
sure from  witliin  have  been  developed.  Should  the  patient  survive  the  compression 
of  the  brain,  the  tumor  ultimately  undergoes  necrosis  and  breaks  down  into  a  dirty 
mass,  in  which  the  process  of  ulceration  is  accompanied  by  frequent  ha?morrhage. 

Carcinoma  of  the  meninges  may  occur  as  a  result  of  metastasis,  although  rarely 
if  ever  occurring  primarily  in  this  situation. 

In  sarcoma  and  carcinoma  of  the  dura  mater  little  more  can  be  done  than  to 
relieve  pain  by  the  employment  of  narcotics.  The  injection  of  the  toxines  of  ery- 
sipelas with  or  without  the  mixture  with  the  bacillus  prodigiosus  should  be  tried 
in  this  as  in  sarcoma  elsewhere. 

Hydrocephalus  is  primarily  a  tubercular  disease  of  the  araclmoid  and  pia  mater 
in  childhood.  The  gross  lesion  is  a  transudation  of  the  serous  fluid  from  the  pia 
and  arachnoid  into  the  cavities  of  the  ventricles,  the  arachnoid,  and  subarachnoid 
spaces.  Distention  of  the  ventricles,  compression  of  the  brain  substance,  separation 
of  the  sutures,  enlargement  and  deformity  of  the  head,  projection  of  the  eyeballs, 
downward  squint,  and  loss  of  cerebral  function,  are  the  S3Tnptoms,  im-ariably 
ending  in  death. 

Treatment. — Tapping  will  at  times  relieve  the  more  urgent  symptoms  of  dis- 
tention and  compression.  Careful  antisepsis  should  be  practiced,  and  the  aspira- 
tion made  through  one  of  the  lateral  angles  of  the  anterior  fontanelle.  A  small 
needle  should  be  introduced,  and  three  or  four  ounces  slowly  withdrawn,  the  opera- 


232     SCALP— SKULI^BRAIN— CRANIAL    NERVES,    SPINAL   CORD    AND    NERVES 

tion  occupying  from  fifteen  to  thirty  minutes.  Tliis  treatment  is  palliative,  and 
is  only  justifiable  in  the  effort  to  relieve  the  suffering  of  the  patient.  A  cure  is 
impossible. 

MiCROCEPHALUS 

Failure  in  development  of  the  brain  may  be  due  to  organic  defect  in  brain 
cells,  or  to  compression  of  this  organ  by  non-expansion  of  the  slvull.  With  the 
former  conditions  surgery  has  nothing  to  do,  but  with  the  latter,  a  condition  of 
true  microcephalus,  operation  is  indicated.  The  author  has  operated  on  a  large 
number  of  these  unfortunate  children,  and  while  none  have  been  made  normal, 
the  physical  and  mental  conditions  have  been  materially  improved  in  a  sufficient 
number  to  justify  its  repetition.  The  death-rate  is  high  (about  fifteen  per  cent), 
but  in  view  of  the  hopeless  condition  of  these  patients,  when  there  is  a  prospect 
of  betterment  any  risk  seems  justifiable. 

There  is  usually  a  history  of  absence  of  the  fontanelles.  The  skull  and  the  head 
is  small  and  cocoanut  shaped.  Lannelongue  proposed  cutting  out  a  strip  from  a 
quarter  to  a  half  inch  wide  on  either  side  of  the  median  line  and  about  an  inch 
away  from  it.  This  operation  does  not  relieve  the  pressure,  and  should  be  modified 
to  include  the  removal  of  the  entire  top  of  the  skull  by  the  following  technic: 
An  incision  is  made  from  the  middle  line  of  the  forehead,  at  the  edge  of  the 
hair,  back  to  near  the  occiput,  the  ha?morrhage  being  at  once  controlled  by 
forceps,  clamps,  compression,  or  a  running  catgut  suture.  A  button  of  bone  is 
removed  with  the  Gait  trephine  or  hand  gouge,  and  the  opening  immediately 
enlarged  with  the  cutting  forcej)S,  which  are  laid  aside  and  the  bone  ra]3idly 
broken  and  torn  off  in  large  pieces  by  the  ordinary  holding  bone  forceps.  As 
the  superior  longitudinal  sinus  in  children  is  not  attached  to  the  under  surface 
of  the  skixll,  the  entire  roof  of  the  calvarium  can  be  removed  for  at  least  two 
inches  on  either  side  of  the  middle  line.  The  dura  mater  is  not  disturljed,  and 
the  periosteum  is  removed  with  the  bone.  The  edges  are  smoothed  by  clipping 
pfp  the  angular  points  of  bone.  The  compression  is  further  relieved  by  catching 
the  remaining  rim  of  skull  to  the  depth  of  one  half  or  three  fourths  of  an  inch 
between  the  jaws  of  the  holding  forceps,  and  straightening  or  prying  it  outward 
(not  imlike  a  half-peeled  orange).  The  operation  is  completed  by  reuniting  the 
scalp  in  the  middle  line  with  a  running  catgut  suture  and  applying  a  light  sterile 
dressing.  There  is  in  almost  all  cases  a  noticealjle  improvement  within  a  week 
or  two.  In  one  instance,  in  the  case  of  a  child  a  year  olcl,  a  double  talipes  equino- 
yarus  disappeared  within  three  months  after  the  pressure  was  relieved. 

Wounds  of  the  scalp  should  be  rendered  aseptic,  and  closed  by  silk  or  linen 
sutures,  or  the  edges  brought  into  apposition  by  a  sterile-gauze  compress  and  band- 
age. The  hair  should  be  trimmed  for  a  fourth  or  half  inch  from  the  edges  of 
the  wound.  When  no  large  vessels  have  been  divided,  the  introduction  of  the 
sutures  will  suffice  to  arrest  the  bleeding.     Cocaine  anesthesia  will  suffice. 

Lacerated  wounds  of  the  scalp  are  at  times  very  extensive  and  formidable.  Sev- 
eral instances  are  reported  of  complete  avulsion  of  the  female  scaljD  from  the  en^ 
tanglement  of  the  hair  in  machinery.  In  such  cases  transplantation  of  integument 
becomes  necessary,  in  order  to  prevent  ostitis  from  denudation  of  the  calvaria. 
Ordinary  lacerated  wounds  should  be  rendered  aseptic,  and  may  be  treated  by  a 
compress  of  sterile  gauze,  or  sutures  employed,  after  the  torn  and  bruised  edges 
have  been  trimmed  off  with  the  scissors. 

Contused  wounds  of  the  scalp  are  usually  followed  by  marked  swelling,  due  to 
extravasation  of  blood  (haematoma)  iDeneath  the  pericranium.  The  treatment  con- 
sists in  cold  applications,  by  means  of  the  ice-l^ag  or  cloths  talien  from  ice  water. 
If  suppuration  occurs,  incision  should  be  promptly  made.  A  form  of  serous  cyst 
sometimes  results  from  hsematoma  of  the  scalp.  It  should  be  treated  by  aspiration, 
and,  if  one  or  two  evacuations  do  not  effect  a  cure,  it  should  be  incised  and  the 
.cj'st  wall  dissected  out. 

Penetrating  Wounds  of  the  Skull  and  Brain — Gunshot. — When  a  foreign  body 
has  penetrated  the  cranial  cavity  and  passed  out,  the  wounds  of  entrance  and  exit 
should  be  cleansed  of  loose  fragments  of  bone  or  any  foreign  substance.     Every 


SCALP— SICULI^BRAIN— CRANIAL   NERVES,   SPINAL   CORD    AND    NERVES     233 

effort  should  be  made  to  prevent  infection.  It  is  often  imperative  to  enlarge  both 
openings  with  a  rongeur  to  secure  free  exit  for  the  escape  of  blood  or  other  fluids 
in  the  track  of  the  missile.  N"o  effort  should  be  made  to  arrest  intracranial  heemor- 
rliage  by  plugging,  for  fatal  compression  of  the  brain  might  result.  If  the  vessels 
involved  cannot  be  reached  by  forceps  without  injury  to  brain  substance,  the  head 
of  the  patient  should  be  elevated,  and  Dawbarn's  sequestration  method  applied  to 
lower  blood  pressure.     Under  no  circumstances  should  a  probe  be  introduced. 

"\Ylien  there  is  only  a  single  op)ening  and  the  missile  is  lodged  within  the  cranium, 
this  wound  should  be  cleared  as  above  described,  and  the  patient  allowed  to  rest 
until  the  ball  is  located  by  a  careful  X-ray  ^Jicture  of  the  brain. 

In  gunshot  wounds,  and  in  other  injuries  of  the  brain,  respiration  is  often  sus- 
pended by  the  shock  to  this  organ,  while  the  heart  still  beats.  With  this  knowledge 
in  mind,  artificial  respiration  should  be  practiced  as  long  as  there  is  hope  of  resus- 
citation. The  introduction  of  a  tube  through  an  incision  in  the  trachea  and  the 
bellows  should  be  called  into  requisition  when  necessary  to  maintain  prolonged 
oxj'genation  of  the  blood. 

In  locating  a  foreign  body  within  the  cranium  by  the  Eoentgen  ray,  great  care 
must  Ijc  taken  to  secure  a  correct  picture. 

In  jjunctured  wounds  the  propriety  of  operation  will  be  determined  by  the  con- 
ditions present.  If  there  are  s^Tuptoms  of  compression,  either  from  haemorrhage 
or  the  presence  of  a  penetrating  body,  or  should  sepsis  supervene,  operation  is  indi- 
cated upon  the  first  appearance  of  the  S3anptoms. 

Brain  Centers. — Successful  brain  surgery  depends  largely  upon  (a)  accurate 
loiowledge  of  the  various  centers  as  determined  by  measurements  upon  the  scalp 
and  skull;  (&)  a  careful  study  of  the  symptoms  present  in  any  given  lesion;  (c) 
the  strictest  asepsis;  (d)  rapidity  of  work;  and  (e)  last,  but  not  least  in  impor- 
tance, the  control  of  bleeding. 

A  useful  scheme  of  localization  is  that  of  Chipault,  an  outline  of  which  is 
given  in  Fig.  293.  The  patient's  head  should  be  smoothly  shaved  and  scrubbed 
with  soajj  and  water.  A  careful  measurement  is  made  from  the  root  of  the  nose 
at  the  naso-frontal  suture  A,  along  the  median  line  of  the  skull  to  the  occipital 
protuberance  B,  and  this  line  is  divided  into  hundredths :  -/^V  of  this  distance  from 
the  naso-frontal  suture  marks  the  precentral  point;  ^W,  the  Eolandic  point;  -^, 
the  Sylvian  point;  ^^,  the  lambdoidal  point;  and  j^t^,  the  lateral  sinus  point. 
From  C  the  retro-orbital  tubercle,  which  can  be  readily  made  out  by  the  finger 
just  behind  the  outer  angle  of  the  orbit,  three  primary  lines  are  drawn  to  the 
tVo"'  tVVj  3nd  rSiJ>g  points,  respectively  named,  from  above  downward,  the  Sylvian, 
the  superior-temporo-sphenoidal,  and  the  lateral  sinus  lines,  and  these  are  again 
subdivided  into  tenths.  From  the  second  tenth  of  the  upper,  or  Sylvian  line,  to 
the  forty-fifth  or  precentral  point,  is  dra-^Ti  the  precentral  line,  and  from  the 
-third  tenth  of  the  Sylvian  line  to  the  fifty-fifth,  or  Eolandic  point,  is  drawn  the 
Eolandic  line.  These  two  (the  most  important)  lines  are  also  subdivided  into 
tenths.  The  various  centers,  as  at  present  recognized,  are  indicated  in  the  descrip- 
tion of  Fig.  293. 

Given  the  symptoms  of  compression  of  the  brain  from  hsemorrhage  between  the 
skull  and  the  dura,  beneath  the  dura,  and  within  the  brain  substance,  or  from  a 
collection  of  pus  or  an  exostosis,  depression  of  bone,  or  neoplasm  within  the  cranium, 
a  careful  analysis  of  all  the  s}'mptoms  present  will  enable  the  surgeon  to  locate 
with  reasonable  certainty  that  portion  of  cerebrum  or  cerebellum  which  is  involved. 

In  all  extensive  operations  upon  the  brain  it  is  advisable  to  have  at  hand  the 
means  of  artificial  respiration — namely,  a  trachea  tube  and  bellows  and  a  tank 
of  oxygen,  the  latter  not  only  to  be  used  in  an  emergency,  but  to  be  combined  with 
the  inhalation  of  the  anesthetic,  for  there  is  less  bleeding  with  than  without  this 
combination.  It  must  be  remembered  that  shoch  is  one  of  the  great  dangers  in 
brain  surgery,  chiefly  on  account  of  hcemorrhage,  but  also  from  traumatism.  Next 
in  importance  is  the  jDrevention  of  sepsis,  as  well  as  the  careful  preparation  of  the 
patient.  If  possible,  at  least  a  week  should  be  given  to  this,  in  which  period  the 
resistance  should  be  brought  as  near  to  the  normal  as  possible.  Two  days  before 
the  operation  the  scalp  should  be  shaved  and  thoroughly  scrubbed  with  warm  water 


234    SCALP— SKULL— BRAIN— CRANIAL    NERVES,    SPINAL    CORD    AND    NERVES 

and  sterile  soft  soap  that  has  just  Ijeen  boiled,  the  sebaceous  matter  and  hair  follicles 
cleaned  out  with  the  free  use  of  ether,  the  whole  surface  thoroughly  mopped  with 
1-3000  mercuric-chloride  solution,  and  a  moist  1-3000  mercuric-chloride  dressing 
laid  on  and  held  in  place  by  a  capelline  bandage.  Just  before  the  operation  the 
scalp  should  be  again  shaved,  and  the  cleansing  process  as  above  given  repeated. 


Tig.  293. — Localization  after  Cliipaiilt.  A.  Fronto-nasal  junction.  B.  Occipital  protuberance. 
C.  Retro-orbital  tubercle.  D.  Sylvian  fissure  line.  E.  Superior  temporo-sphenoidal  line.  F.  Lat- 
eral sinus  line.  G.  Precentral  line.  H.  Rolandic  line.  I.  Junction  of  second  and  third  tenths  of 
Sylvian  line.  J.  Junction  of  third  and  fourth  tenths  of  Sylvian  line.  K.  Lateral  sinus.  45.  Pre- 
central point.  55.  Rolandic  point.  70.  Sylvian  point.  80.  Superior  temporo-sphenoidal  point. 
95.  Lateral  sinus  point.  1.  Motor  and  sensory  disturbances,  lower  extremities.  2.  Motor  and 
sensory  disturbances,  upper  extremities.  3.  Motor  and  sensory  disturbances,  face,  tongue,  jaw, 
pharynx,  vocal  cords.  Motor  aphasia  in  right-handed  people  and  vice  versa.  Upper  4.  Movements 
of  the  body  (posterior  part  of  the  first  frontal  convolution).  Lower  4.  Movements  of  the  head  and 
neck  (posterior  part  of  second  frontal  convolution).  Lower  4.  Associated  movements  of  the  eyes  and 
head.  5.  Tactile  and  muscular  sensibility.  6.  Hemianopsia  and  word-blindness,  agraphia  and  para- 
phasia. 7.  Intelligence.  8.  Storageof  visual  images  (cuneus,  lingual  lobe  and  calcerine  fissure  cannot 
be  seen).  9.  Audition.  10.  Images  for  words  heard  and  musical  tones  (left  side).  In  this  same 
region  on  both  sides,  the  sensory  motor  auditory  center  exists.  The  internal  frontal  convolution 
lies  in  the  longitudinal  fissure,  opposite  the  superior  frontal  convolution.  The  paracentral  convolu- 
tion lies  in  the  longitudinal  fissure  opposite  the  ascending  frontal,  between  the  45%  and  55%  points. 
The  quadrate  lobe  lies  in  the  longitudinal  fissure  opposite  the  ascending  and  inferior  parietal  con- 
volutions, between  the  Rolandic  and  Sylvian  lines,  that  is,  the  55%  and  70%  points.  The  cuneus, 
lingual,  and  the  fusiform  lobes,  first,  second,  and  third  occipital  convolutions,  are  between  the  70% 
and  95%  lines.      (After  Ayer  and  Spitzka,  Hartley,  Kenyon  and  Bickham.) 

Before  commencing  the  operation  all  measurements  should  be  carefully  made  and 
the  various  lines  which  may  bear  upon  the  procedure  to  be  carried  out  indicated 
by  sterile  iodine  or  fuchsin  stain. 

In  the  selection  of  the  anssthetic,  ether  with  oxygen  should  be  used. 

The  position  of  the  patient  on  the  table  should  be  the  one  most  convenient  to 
the  operator,  with  the  head  and  body  slightly  elevated.     A  rubber  tube-tourniquet. 


SCALP— SKULI^BRAIN— CRANIAL    NERVES,   SPINAL    CORD    AND    NERVES     235 

or  flat  band,  is  applied  around  the  head  beneath  the  occiput,  above  the  ears  and 
e3'ebrows,  and  is  kept  from  slipping  over  the  eyes  by  a  sterile  tape  passing  along 
the  median  line  of  the  skull  from  before  backward.  If  to  this  Dawbarn's  seques- 
tration method  be  added,  the  liEemorrhage  will  be  materially  lessened. 

For  the  removal  of  tumors,  or  for  any  operation  requiring  the  extra-  or  intra- 
dural exposure  and  exploration  of  a  considerable  brain  area,  the  solid  horseshoe- 
shaped  or  irregularly  quadrilateral  flap  of  scalp  and  bone  is  preferred.  It  is  essen- 
tial that  the  arterial  supply  to  the  flap  be  preserved.  For  this  reason,  the  temporal 
and  meningeal  arteries  are  usually  included  in  the  base  or  hinge  when  operating 
laterally,  and  the  occipiital  and  frontal  arteries  when  operating  upon  other  portions 
of  the  skull.  Guarding  against  ha?morrhage  should  commence  with  the  operation. 
The  incision  through  the  scalp  shoitld  be  rapidly  made  down  to  the  bone,  and  the 
bleeding  at  once  arrested  by  compression  or  by  the  use  of  Kredal's  steel  plates.^ 
The  structure  of  the  scalp  is  such  that  it  is  extremely  difficult  to  grasp  the  end 
of  bleeding  vessels  with  the  forceps,  and  clamping  it  tightly  is  apt  to  produce  tissue 
necrosis.  For  this  reason,  when  clamjjs  are  not  at  hand,  a  temporary  running 
suture  of  linen  will  control  this  source  of  haemorrhage.  By  the  time  the  operation 
is  tuiislied  most  of  these  bleeding  points  will  be  stopped  by  coagula.  The  perios- 
teum should  he  stripped  back  one  eighth  of  an  inch  toward  the  flap  to  be  elevated, 
and  two  eighths  of  an  inch  on  the  opposite  side  of  the  incision,  and  at  certain  points 
slightl}'  wider  for  the  trephine.  A  half-inch  trephine  (a  smaller  opening  will  suffice 
with  Masland's  saw)  is  now  inserted  at  one  of  the  upper  angles  of  the  wound  (see 


Fig.  294. — 1,  Ascending  frontal  convolution.  2,  Precentral  sulcus.  3,  Ascending  limb  of  the  Sylvian 
fissure.  4,  Inferior  parietal  convolution.  5,  Fissure  of  Rolando.  6,  Ascending  parietal  convolu- 
tion. 7,  Supramarginal  convolution.  8,  Fissure  of  Sylvius.  9,  Superior  ternporo-splienoidal 
convolution.  10,  First  temporo-sphenoidal  sulcus.  11,  Second  temporo-sphenoidal  convolution. 
(Hartley  and  Kenyon.) 

Fig.  294),  and  a  button  of  bone  removed  down  to  the  dura.  The  concussion  of 
the  mallet  stroke  makes  the  chisel  objectionable.  Two  other  smaller  trephine  holes 
are  cut  in  the  same  line,  and  along  the  descending  planes  of  the  proposed  incision 
through  the  bone  other  holes  are  made  (Fig.  294). 

'  "Centralblatt  fiir  Chirurgie,"  No.  43,  1906,  Hartley  and  Kenyon. 


236     SCALP— SKULL— BRAIN— CRANIAL    NERVES,    SPINAL    CORD    AND    NERVES 

In  rajDidly  dividing  the  skull  in  these  operations,  the  Masland  saw  ^  or  Hartley's 
apparatus  ^  in  the  hands  of  an  expert  are  invaluable,  for  time  is  exceedingly  im- 
portant in  this  field  of  surgery.  In  their  absence  the  next  best  method  is  the  Gigli 
wire  saw,  which  will  require  a  larger  trephine.  Through  this  larger  trephine  hole 
a  dull-pointed  flexible,  grooved  director  should  be  inserted,  and  the  dura  mater 
carefully  separated  from  the  bone  in  the  line  to  the  nearest  trephine  opening.  Along 
the  trough  of  the  director  the  guide  for  the  introduction  of  the  wire  saw  is  inserted, 
and  this  instrument  pulled  through,  the  director  protecting  the  dura  from  injury. 
A  few  strokes  should  divide  this  strip  of  slmll,  preferably  with  a  slight  outward 
bevel.  This  technic  is  rapidly  repeated  until  the  section  of  bone  is  complete.  In 
breaking  the  bone  flap  at  the  base,  proceed  as  follows:  Insert  two  strong,  narrow 
instruments  at  the  two  lower  angles,  and  make  slight  pressure  with  these,  while 
a  third  and  larger  elevator  is  placed  in  the  center  of  the  upper  line,  where  greater 
lifting  force  is  exercised.  If  this  be  deftly  done  the  line  of  fracture  will  be  between 
the  points  of  the  two  lower  instruments.  This  trap-door  flap,  composed  of  bone 
and  undisturbed  periosteum  and  scalp,  is  now  enveloped  in  gauze  wet  in  hot  normal 
salt  solution  and  turned  down  and  kejst  warm.  The  hfemorrhage  from  the  bone 
is  at  times  severe,  necessitating  rapid  use  of  the  saw,  so  that  the  bone  may  be 
quickly  fractured  and  the  flap  turned  down  in  order  to  expose  the  bleeding  surfaces. 
All  bleeding  points  shoi;ld  be  packed  at  once  with  Horsley's  sterile  wax,  or  pref- 
erably a  strong  bone  forceps  should  be  used  to  pinch  the  two  edges  of  the  cal- 
varium  together  over  the  bleeding  points,  crushing  the  vessel  walls  together  with 
the  diploe.  Any  severe  oozing  should  be  stopped  by  applying  hot  salt  solution, 
either  by  irrigation  or  gauze  jjads,  before  the  dura  is  opened.  In  case  the  Gigli 
saw,  or  the  more  modern  apparatus  of  Hartley  and  Masland,  are  not  used,  the 
bone  between  the  trejjhine  openings  may  be  cut  away  with  the  De  Vilbiss  cutter 
(Fig.  24),  a  very  excellent  instrument  for  this  purpose;  or,  in  an  emergency,  the 
old-fashioned  von  Bruns"  bone  cutter  may  be  employed.  The  objection  to  these 
last  two  instruments  is  that  they  remove  a  rather  wide  strip  of  bone. 

At  this  stage  of  the  operation  a  careful  note  should  be  made  of  the  patient's 
condition — the  pulse,  the  character  of  the  respiration,  etc.  The  pulse  is  deemed  so 
important  an  index  that  Hartley  advises  the  use  of  a  sphygmograph  throughout 
the  operation,  with  an  indicator  so  arranged  that  any  marked  changes  in  heart 
action  may  be  at  once  observed.  If  everything  be  favorable,  the  operation  may 
proceed,  but  if  there  be  doubt  in  the  mind  of  the  operator,  he  should  rather  lean 
to  the  side  of  conservatism  and  consider  this  the  first  stage  in  the  operation,  re- 
placing the  flaj)  temporarily  and  applying  an  aseptic  dressing,  and  waiting  two  or 
three  days  for  complete  reaction  and  recovery  to  continue  the  oj)eration  by  opening 
the  dura.  AVith  the  modern  saws  and  trephines  run  by  electric  motor  power,  the 
time  consiimed  in  reaching  the  brain  surface  is  so  much  shorter  that  operations  in 
two  stages  are  now  comparatively  infrequent.  In  cutting  the  dura,  the  section 
should  be  about  one  quarter  of  an  inch  from  the  bone,  so  that  resuture  may  be 
easier.  In  turning  the  dural  flap,  the  hinge  should  be  where  the  meningeal  ves- 
sels enter.  Any  hemorrhage  should  be  arrested  at  once  by  fine  catgut  ligatures, 
and  in  lifting  the  dura  great  care  should  be  taken  to  avoid  the  delicate  plexus  of 
vessels  ujjon  the  cortex.  Should  there  be  found  an  extra-dural  clot  it  will,  of 
course,  be  unnecessary  to  expose  the  brain  by  opening  the  dura.  The  coagulum 
should  be  carefully  removed,  preferably  by  irrigation  with  hot  salt  solution.  If 
subdural,  the  same  method  should  be  cmplo3'ed,  and  in  brain  clot  irrigation  from 
a  small  pipette,  with  force  well  regulated,  is  preferable  to  removing  it  by  gauze. 

Should  a  tumor  be  discovered,  this,  of  course,  must  be  removed  with  more  or 
less  injury  to  contiguous  brain  substance,  and  usually  can  be  best  accomplished  with 
a  dull-pointed  curved  scissors,  or  with  the  finger  of  the  operator.  Hemorrhage 
should  be  arrested  before  the  dura  is  resutured.  Fine  catgut  ligatures  will  control 
larger  points  of  bleeding,  while  hot  salt  solution  will  arrest  oozing.  The  dura 
should  be  closed  with  a  running  catgut  suture,  and  in  case  of  persistent  oozing, 
delicate  bundles  of  this  material  may  be  left  at  one  or  two  points  to  facilitate  the 
escape  of  any  transudate.  The  trap-door  flap  should  now  be  brought  into  its  nor- 
'  "Annals  of  Surgery,"  August,  1906.  ^  Ibid.,  April,  1907. 


SCALP— SKULI^BRAIX— CRANIAL    NERVES,    SPINAL   CORD    AND    NERVES     237 

mal  position,  wliere  it  will  remain  with  no  other  sutures  than  those  passed  deeply 
through  the  scalp  and  periosteum.  Additional  chromic-acid  catgut  bundle  drains 
should  be  inserted  at  one  or  two  points  for  drainage,  and  an  aseptic  dressing  applied 
over  all. 

The  lines  of  incision  and  field  of  exposure  sho'mi  in  this  lateral  operation  may 
be  extended  forward  or  backward,  as  recpiired.     The  occipital  arteries  are  left  in 


Fig.  295. — Trap-door  exposure  of  the  occipital  region.  1,  Supramarginal  convolution.  2,  Inferior 
parietal  convolution.  3,  Angular  convolution.  4,  External  parieto-occipital  fissure.  5,  First  oc- 
cipital convolution.  6,  Superior  longitudinal  sinus.  7,  Second  occipital  convolution.  8,  Third 
occipital  convolution.  9,  Lateral  sinus.  10,  External  occipital  protuberance.  11,  Dural  flap. 
In  this  region  of  the  skull  exposed  by  tliis  flap,  we  have  one  case.     (Hartley  and  Kenyon.) 

the  pedicle  of  the  flap  for  the  posterior  operations  (Fig.  295).  When  an  exten- 
sion of  the  lateral  operation  forward  may  not  meet  all  the  indications,  a  frontal 
bone  flap  may  be  made,  leaving  one  or  Ijoth  frontal  arteries  in  the  jsedicle. 


Interceanial  Lesioxs — TuiroR — H.5;moeehage — Abscess 

Compression  of  the  brain,  in  addition  to  that  caused  by  foreign  bodies  or  de- 
pressed fractures,  or  traumatic  ha?morrhage  may  also  he  due  to  neoplasms,  collec- 
tions of  pus  connected  or  not  with  an  injury,  and  by  haemorrhage  as  well,  which 
occurs  at  times  without  appreciable  cause.  One  of  the  most  frequent  forms  of  com- 
pression is  that  due  to  collections  of  tuberculous  material  while  the  lesions  of 
syphilis  (gumma  and  various  lesions  of  the  arteries)  and  glioma,  cysts,  carcinoma, 
sarcoma,  and  fibroma  are  found. 

Tumors. — The  ordinary  s}'mptoms  of  brain  tumor  are  headache  (worse  on 
waking),  vomiting  of  a  projective  type  not  associated  with  ingesta,  vertigo  (de- 
veloping upon  change  of  position),  optic  neuritis,  and  mental  dullness.  If  to  these 
symptoms  are  added  either  Jacksonian  epilepsy,  paralysis,  at  first  limited  to  one 
group  of  muscles  or  to  a  single  limb  and  extending  gradually  to  other  parts,  or  if 
there  is  some  form  of  aphasia  or  hemianopsia,  with  staggering  or  uncertaint}'  of 
balance,  the  diagnosis  of  a  tumor  is  reasonably  certain,  although  its  location  may 
not  be  assured.     \Yhen  the  localizing  signs  are  absent,  operation  gives  little  or  no 


238    SCALP— SKULI^BRAIN— CRANIAL   NERVES,   SPINAL   CORD   AND   NERVES 

promise  (Starr).  This  author  conekides  that  about  ten  per  cent  of  tumors  are 
open  to  surgical  treatment. 

Those  which  lie  in  or  near  the  Eolandic  and  Sylvian  fissures  are  more  readily 
diagnosticated,  and  give  better  results  as  to  operation  and  improvement  than  when 
more  deeply  seated.  With  the  foregoing  symptoms  present,  and  with  evidences 
of  the  comjDression  of  a  recognized  brain  center,  an  operation  is  imperative.  The 
indications  as  to  localization  already  given  should  suffice  to  lead  the  operator  to 
the  area  of  disease.  When  there  exists  severe  and  contimious  pain,  with  increasing 
mental  dullness,  although  there  are  no  well-defined  sjanptoms  of  localization  present, 
an  exploratory  operation  is  justified,  and  should  no  lesion  be  discovered  decom- 
pression is  indicated. 

Exploration. — In  undertaking  an  exploratory  operation  upon  the  brain,  it  is 
important  to  utilize  that  point  of  the  cranial  surface  which,  by  the  smallest  possible 
opening,  will  give  the  largest  scope  for  intracranial  search,  and  at  the  same  time 
prevent  the  possibility  of  serious  post-operative  cerebral  hernia. 


Fig.  296. — Sketch  of  the  intemiusculo-temporal  field  of  operation,  showing  exposure  with  bone  defect 

partially  made. 

Two  methods  ma]^  be  followed — the  trap-door  procedure  already  given  or  the 
intermusculo-temporal  operation  of  Dr.  Harvey  Gushing   (Fig.  29G)  : 

"  A  curved  incision  is  made  over  the  side  of  the  head  concentric  with  and  about 
one  centimeter  within  the  line  of  origin  of  the  M.  temporalis  at  the  temporal  ridge 
(Fig.  397).  In  order  not  to  divide  the  filament  of  the  facial  nerve  which  supplies 
the  frontal  portion  of  the  occipito-frontalis  muscle,  it  should  not  extend  anterior 
to  the  hair  margin  and  its  posterior  angle  may  be  advantageously  carried  somewhat 
lower  than  the  anterior.  The  scalp  and  the  aponeurotic  membrane  are  reflected 
downward,  leaving  bare  the  temporal  fascia.  An  incision  is  made  through  this 
semi-transparent  fascia  in  the  line  of  the  fibers  at  about  the  central  part  of  the 
muscle  where  the  fibers  run  in  an  oblique  direction  downward  and  forward.  Less 
room  will  be  had  if  a  point  is  chosen  where  the  fibers  are  more  vertical,  and  their 
course  from  origin  to  insertion  consequently  shorter.  The  fascial  edges  are  re- 
tracted, exposing  the  muscle  bundles.  The  incision  is  carried  down  to  the  bone 
in  an  interspace  between  the  muscle  bundles  which  are  not  divided.  The  anterior 
and  posterior  borders  are  retracted  as  widely  as  possible  and  at  the  same  time  lifted 
from  the  skull,  while  the  periosteum,  as  far  as  it  can  be  reached,  is  scraped  back 
with  an  elevator  from  the  bony  surface  that  underlies  the  muscle.    A  small  primary 


SCALP— SKULL— BRAIN— CRANIAL   NERVES,   SPINAL    CORt)    AND    NERVES     239 


opening  is  made  through  the  exposed  squamous  portion  of  the  temporal.  This  is 
enlarged  with  rongeurs  or  ordinary  boue  forceps  to  the  desired  size,  the  dura  having 
been  separated  in  advance  (Fig.  296).  '  It  is  necessary  to  have  rather  flat  instru- 
ments, as  the  fascia  and  muscle  cannot  be  lifted  away  from  the  bone  sufficiently  far 
to  allow  of  the  introduction  of  thick-bladed  instruments  under 
them.  The  opening  may  be  about  six  centimeters  in  its  vertical 
by  eight  centimeters  in  its  antero-posterior  diameter. 

"Bleeding  from  the  diploe  may  be  particularly  troublesome, 
and  frequently  necessitates  the  use  of  wax.  Care  must  be  taken 
while  biting  away  pieces  of  bone  from  under  the  muscle  ante- 
riorly, lest  injury  to  the  meningeal  be  occasioned." 

The  extent  of  the  incision  in  the  dura  will  be  determined 
by   the  nature  of   the  operation.     If   an   abscess   is   suspected, 
a   small  puncture  at  some  point  near  the  center  of  the  field 
where   the  vessels   may   be  avoided   will   suffice   for   the   intro- 
duction  into   the  brain 
substance    of    the   dull- 
pointed    grooved    direc- 
tor, or  preferably  Jack- 
son's   exploring   dilator 
(Fig.  396a). 

Should  an  abscess  be  discovered,  if  it  can  be  drained  to  advantage  from  this 
level,  a  suitable  incision  of  the  dura  should  be  made  and  drainage  instituted,  or  a 


Fig.  20Ga. — Jackson's  exploring  dilator. 


Fig.  297. — Photograph  of  patient  four  days  after  a  decompressive  operation  by  the  temporal  route. 
Note  anterior  limit  of  the  incision  at  the  hairline,  stopping  short  of  the  nerve  to  the  occipito-fron- 
talis.  In  Cushing's  operation  for  the  extirpation  of  the  Gasserian  ganglion  the  curve  ends  near  the 
upper  attachment  of  the  auricle,  not  behind  the  concha.      (After  Gushing.) 

second  bone  incision  may  be  made.    An  operable  tumor  would  probably  require  an 
osteoplastic  flap,  but  if  inoperable  and  decompression  is  indicated,  the  bone  defect 


240    SCALP— SKULI^BRAIN—CHANIAL   NERVES,   SPINAL   CORD   AND   NERVES 

should  be  enlarged  to  the  requisite  size  and  "  the  dura  should  be  incised  and  cut 
away  to  its  very  margins.  Here,  again,  some  care  must  be  exercised,  for  with  a 
tense  brain,  which  bulges  tightly  against  the  dura,  cortical  injuries  may  be  occa- 
sioned; an  accident  which  always  increases  the  amount  of  subsequent  protrusion, 


Fig.  298. — Sketch  to  show  the  relation  of  the  temporal  bone  defect  to  the  underlying  cortex  .and  the 
denuded  area  which  will  form  the  protrusion  in  Cushing's  decompression  operation.  (After  Gush- 
ing.) 

owing  to  the  consequent  hEemorrhage  and  oedema.  The  dural  incisions,  too,  should 
radiate  in  line  with  the  posterior  branch  of  the  middle  meningeal  artery,  after  its 
ligation  and  division  in  the  midfield,  lest  accidental  injury  of  the  vessel  far  under 
the  muscle  edge  give  annoying  haemorrhage.  With  the  exception  of  this  main  vessel, 
the  pressure  of  the  protruding  brain  against  the  edge  of  the  bone  defect  should 
control  the  oozing  from  the  intervening  fringe  of  dura.  The  area  of  the  cortex 
which  protrudes  and  makes  up  the  hernia  is  shown  in  Fig.  298.  It  will  be  seen 
that  the  temporo-sphenoidal  lobe  constitutes  the  chief  portion.  Over  the  denuded 
bone,  the  split  temporal  muscle  is  then  brought  together  with  fine  black  silk 
sutures.  The  fascia  is  similarly  closed,  and  it  is  necessary  to  place  the  sutures 
at  the  very  edges  of  the  incision,  else  the  inelastic  fibrous  membrane  will  not  be 
satisfactorily  brought  together.  A  few  sutures  may  then  be  placed  in  the  occipito- 
frontal aponeurosis  before  closing  the  scalp.  For  the  scalp,  accurate  af)proxima- 
tion  of  flat  surfaces  is  desirable  for  the  sake  of  controlling  hfemorrhage — very 
rarely   are  any   ligatures  placed   in  the   scalp — though   there  is  less   reason  here 


SCALP— SKULI^-BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES     241 

for  the  extreme  precautions  which  closure  of  the  scalp  demands  when  it  alone, 
without  any  underlying  muscle  and  fascia,  must  withstand  the  pressure  of  the 
resultuig  protrusion.  The  sutures  in  all  cases  are  removed  in  forty-eight  hours 
and  the  wound  protected,  if  need  be,  with  collodion  gauze  strips." 

Through  this  approach,  as  will  be  described  later,  it  is  possible  to  reach  the  sen- 
sory branches  of  the  trifacial,  and  in  the  employment  of  alcohol  injections  this 
may  be  considered  a  more  accurate  route  in  guiding  the  needle  to  the  foramina 
ovale  and  rotundum  without  danger  to  other  organs.  In  this  latter  procedure  the 
cavity  of  the  skull  would,  of  course,  not  be  entered. 

Dr.  Harvey  Gushing  has,  in  a  number  of  instances  in  fractures  of  the  base, 
successfully  drained  the  subdural  space  through  this  route.  He  commends  it  highly 
in  exploration  for  extra-dural  meningeal  clot  or  abscess  of  the  temporal  lobe. 

There  can  be  no  clearer  surgical  indication  than  to  relieve  compression  in  these 
hopeless  cases  of  intracranial  tumor.  A  large  proportion  of  these  neoplasms  cannot 
as  yet  be  accurately  located,  and  when  found  many  are  inoperable.  Nothing  remains 
but  to  lift  the  skull  and  dura  and  permit  expansion. 

The  author  had  done  this  operation  as  early  as  1890  with  immediate  return 
of  consciousness  after  prolonged  coma.  In  these  cases  the  trap-door  operation  was 
done,  leaving  the  bone  and  dura  standing  well  away  from  their  former  relations 
and  reuniting  the  more  elastic  scalp.  The  procedure  of  Gushing  when  available 
is  to  be  preferred. 


Pig.  299. — Solid  flap  of  periosteum  and  temporal  fascia  lifted  and  ready  to  be  turned  bottom-side  up  to 
coA'er  cranial  defect.      (Carl  Beck.) 


242    SCALP— SKULI^BRAIN— CRANIAL  NERVES,   SPINAL   CORD   AND   NERVES 

Cranial  Defects. — Under  other  conditions  than  compression  from  neoplasms, 
the  prevention  of  cerebral  hernia  is  important.  After  fractures  with  ostitis  or 
after  extensive  destruction  of  the  skull  from  syphilis  or  necrosis,  the  muscular 
and  fascial  coverings  of  the  cranium  may  be  utilized  in  plastic  procedures  to  cover 
such  defects  and  limit  or  prevent  hernia.    Fig.  299  illustrates  an  operation  devised 


Fig.  299a. — The  temporal  fascia,  muscle,  and  periosteum  sutured  to  the  edge  of  the  dura  mater. 
(After  Beck.) 

by  Prof.  Carl  Beck,  in  which  a  solid  flap  of  the  temporal  fascia,  muscle,  and  perios- 
teum, is  turned  up  to  be  stitched  to  the  margin  of  the  dura  mater,  the  scalp  to 
be  resutured  in  its  normal  position.  A  similar  use  may  be  made  of  the  occijjito- 
frontalis  or  the  superficial  muscles  of  the  back  of  the  head. 

Cerebral  Haemorrhage. — Hggmorrhages  associated  with  the  dura,  whether  imme- 
diately beneath  this  membrane  or  extra-dural,  may  be  readily  diagnosticated  when, 
after  a  blow  upon  the  lateral  aspect  of  the  skull  over  the  course  of  the  meningeal 
vessels,  there  is  developed  an  abnormally  slow  pulse,  a  steady  rise  in  blood  pressure, 
a  gradually  deepening  coma  and  increasing  hemiplegia,  with  Cheyne- Stokes  res- 
piration.   AVith  these  S3'mptoms  an  immediate  operation  is  imperative. 

In  deeper  hfemorrhages,  intracerebral  or  cerebellar,  even  when  no  external  in- 
jury has  been  received  (apoplexy).  Gushing  states  that  when  the  pressure  rises 
steadily  to  two  hundred  and  fifty  millimeters,^  and  when  with  this  rise  there 
is  a  slow  pulse,  falling  to  as  low  as  fifty  a  minute,  a  fatal  result  is  inevitable 
and  Justifies  exploration.    Under  such  conditions  a  large  trap-door  flap  should  be 

»  Measured  on  the  Riva  Roca  apparatus. 


SCALP— SKULI^— BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES     243 

turned  do-mi  on  the  side  oiJioosite  to  tlie  paralysis,  the  dura  divided,  the  brain 
explored,  and,  if  necessary,  the  exploration  completed  as  a  decompressive  pro- 
cedure, or  the  intermusculo-teniporal  operation  may  be  substituted. 

In  another  form  of  htemorrhage-compression,  in  the  new-born  occurring  with 
protracted  and  difficult  labor,  whether  or  not  instruments  have  been  employed, 
the  surgeon  should  advise  immediate  lifting  of  the  skull  and  removal  of  the  clot. 
In  many  of  these  cases,  and  in  other  deeper  hemorrhages  of  the  brain,  the  aspira- 
tion by  lumbar  puncture  of  bloody  cerebro-spinal  fluid,  will  confirm  the  suspicion 
of  central  haemorrhage. 

Aiscess. — When  not  connected  with  a  penetrating  wound,  or  the  presence  of 
a  foreign  body,  or  a  fracture,  abscess  of  the  brain  is  in  such  a  large  proportion 
of  cases  connected  with  infection  of  the  middle  and  internal  ear,  or  of  the  mas- 
toid process  and  lateral  sinus,  that  this  lesion  will  be  considered  with  the  surgery  of 
the  ear.  Abscess  of  the  brain,  of  traumatic  origin,  which  produces  definite  cerebral 
symptoms,  can  be  diagnosticated  and  should  be  operated  on  as  soon  as  recognized. 
In  cases  of  fracture  of  the  skull,  or  concussion,  followed  within  two  or  three  weeks 
by  the  development  of  symptoms  suggestive  of  abscess,  it  is  imperative  to  trephine, 
even  though  the  sjonptoms  are  purely  subjective. 

These  are  headache,  vertigo,  vomiting,  slow  pulse,  marked  change  in  the  mental 
state,  dullness,  irritability  of  temper,  defective  memory,  despondency,  tenderness 
on  percussion,  irregular  pupils,  and  optic  neuritis  (Starr).  When  meningitis 
occurs,  as  a  rule  lumbar  puncture  will  reveal  an  increased  number  of  leucocytes  in 
the  cerebrospinal  fluid,  together  with  the  micro-organisms  of  sepsis.  The  blood 
count  is  essential,  since  sudden  and  great  increase  in  the  leucocytes  is  an  indication 
of  a  cerebral  complication.  The  leucocyte  count  in  meningitis  is  usually  higher 
than  that  in  abscess. 

Aspiration  of  the  Ventricles. — In  exploration  of  the  brain  it  is  occasionally 
desirable  to  aspirate  the  lateral  ventricles.  Prof.  W.  W.  Keen  has  laid  down  the 
following  rules  of  procedure: 

To  aspirate  the  lateral  ventricle:  I.  Trephine  half-way  from  the  external  oc-  . 
cipital  protuberance  to  the  upper  end  of  the  fissure   of  Eolando,  half  to  three 


Fig.  300. — Antero-posterior  section  of  the  head  half  an  inch  from  the  median  line.  R,  Fi.ssure  of 
Rolando.  /,  Inion.  A  and  B,  (solid)  lines  of  puncture,  the  dotted  lines  showing  their  imaginary 
continuation  to  the  fixed  points.     (After  Keen.) 

quarters  of  an  inch  to  either  side  of  the  middle  line.  Puncture  toward  the  inner 
end  of  the  supra-orbital  ridge  of  the  same  side  (Fig.  300  A).  The  puncture  will 
pass  through  the  precuneus,  and  the  normal  ventricle  will  be  struck  at  some  point 
in  the  posterior  horn  at  from  two  inches  and  a  quarter  to  two  inches  and  three 
quarters  from  the  surface  of  scalp. 

II.  Trephine  at  one  third  of  the  distance  from  the  glabella  to  the  upper  end 


244     SCALP— SKULL— BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES 

of  the  fissure  of  Eolando  and  half  to  three  quarters  of  an  inch  to  either  side  of 
the  middle  line.  Puncture  in  the  direction  of  the  external  occipital  protuberance 
(Fig.  300  B).  The  puncture  will  traverse  the  first  frontal  convolution  well  in 
front  of  the  motor  zone,  and  the  normal  ventricle  will  be  struck  in  the  anterior  horn 
at  about  two  inches  to  two  inches  and  a  quarter  from  the  scalp. 

III.  Trephine  one  and  one  fourth  inch  behind  the  meatus  and  one  and  one 
fourth  inch  above  Eeid's  base  line.  (This  line  extends  from  the  lowest  part  of  the 
infra-orbital  margin  through  the  middle  of  the  external  meatus  to  the  ear.) 

Puncture  toward  a  point  two  and  one  half  inches  directly  behind  the  opposite 
meatus    (Fig.   301).     The  puncture  will  traverse  the  second  temporo-sphenoidal 


^/<?  BASE  L 


Fig.  301. — Diagram  to  show  the  relations  of  the  brain  to  tlie  skull  (modified  from  Reid).  J  b,  Coronal 
suture ;  b,  bregma ;  F,  external  angular  process ;  H,  lambda ;  H  c,  lambdoid  suture ;  j,  pterion ;  M,  mastoid 
process;  x,  parietal  eminence;  S3^  a.,  Sy.  P.,  anterior  and  posterior  limbs  of  Sylvian  fissures;  F.  of  R., 
fissure  of  Rolando;  a.  f.  c,  a.  p.  c,  ascending  frontal  and  ascending  parietal  convolutions;  s.  F.  s.,  i. 
r.  s.,  suijerior  and  interior  frontal  sulci;  1  r.  c,  2  r.  c,  3  F.  c,  frontal  convolutions  ;  s.  T.-s.  s.,  su- 
perior and  inferior  temporo-sphenoidal  sulci;  1  T.-s.  c,  2  T.-s.  c,  3  t.-s.  c,  temporo-sphenoidal 
convolutions;  i.  p.  s.,  intraparietal  suture;  s.  p.  L.,  superior  parietal  lobule;  s.  M.  c,  supra-marginal 
convolutions;  a.  g.,  angular  gyrus;  p.  o.  F.,  parieto-occipital  fissure;  o.  l.,  occipital  lobe;  G,  c,  m,  a, 
Reid's  base  line. 


convolution  and  enter  the  normal  lateral  ventricle  at  the  beginning  or  in  the  course 
of  the  descending  eornu  at  a  depth  of  about  two  to  two  and  one  fourth  inches 
from  the  surface.  In  this  route  the  measurements  are  for  an  adult  sloill.  They 
should  be  somewhat  reduced  for  children.  The  depth  necessary  for  f)uncture  will 
depend  somewhat  upon  the  thiclaiess  of  the  sloill  and  variations  in  the  diameter 
of  the  slaill  from  youth  to  old  age,  as  well  as  upon  the  distention  of  the  ventricle 
with  effusion.  This,  the  lateral  route,  has  the  great  disadvantage  that  it  will 
develop  an  abscess  of  the  temporo-sphenoidal  lobe,  as  well  as  dropsy  of  the  ventricle. 
It  is  well  to  state  that  the  center  for  hearing  of  the  opposite  side  may  be  pene- 
trated through  this  opening,  but,  as  it  has  been  done  a  number  of  times  without 
impairment  to  the  hearing,  this  objection  should  not  prevent  the  operation.  At 
the  ventricular  end  of  the  puncture  the  optic  thalamus  may  be  injured,  but  this  risk 
must  be  taken. 

The  Surgical  Treatment  of  Epilepsy. — In  about  ten  per  cent  of  all  epileptics 
the  convulsions  are  due  to  a  focus  of  irritation  caused  by  an  injury  or  to  inflam- 
matory adhesions,  or  to  the  presence  of  a  neoplasm  of  the  bony  envelope,  the 
membranes,  or  the  brain  substance  proper.     Wlien  it  can  be  demonstrated  by  cere- 


SCALP— SKULI^BRAIN— CRANIAL   NERVES,    SPINAL   CORD   AND   NERVES     245 

bral  localization  that  a  given  point  in  the  brain  is  affected,  it  is  justifiahle  to 
explore  the  suspected  focus  of  disturbance.  Wlien  epileptic  seizures  habitually 
begin  with  twitching  of  a  single  muscle  or  group  of  muscles  (as  of  the  thumb, 
liand,  or  facial  muscles  of  one  side)  before  the  general  convulsion  is  precipitated, 
it  is  quite  probable  that  the  area  from  which  these  motor  impulses  originate  is 
involved.  The  same  is  true  of  sensory  phenomena,  although  these  are  compara- 
tively rare. 

The  operative  technic  diifers  in  no  essential  feature  from  that  already  given. 
The  osteoplastic  flap  is  in  general  to  be  preferred,  and  its  shape  and  position  may 
be  modified  to  suit  the  region  of  the  slaiU  to  be  temporarily  lifted.  Should  per- 
manent removal  of  bone  be  considered  advisable,  the  bone  flap  may  be  partially 
or  completely  cut  away  and  the  dura  and  scalp  resutured,  or  the  bone  may  be 
not  quite  restored  to  its  original  level,  the  scalp  being  stretched  and  resutured  over 
the  elevated  fragment.  On  account  of  the  great  danger  of  cerebral  hernia,  an  area 
larger  than  an  inch  in  diameter  should  not  be  entirely  removed  unless  jjrotected 
by  a  covering  of  muscle  or  strong  fascia. 

Trifacial  Neuralgia. — Neuritis  of  one  or  more  of  the  branches  of  this  nerve  or 
of  the  Gasserian  ganglion  is  one  of  the  most  painful  of  human  maladies,  and  its 
relief  one  of  the  most  perplexing  problems  in  surgery. 

The  one  most  generally  successful  procedure  is  the  removal  by  excision  of  the 
entire  ganglion  and  its  three  offshoots,  or  its  destruction  by  direct  or  indirect 
avulsion.  The  former  procedure  is  so  formidable  and  hazardous,  involving  an 
invasion  of  the  cranial  cavity,  that  in  view  of  even  the  qualified  success  which  has 
been  reported  by  less  dangerous  methods,  these  are  first  entitled  to  a  thorough 
trial.  They  are  the  injection  of  alcohol  into  or  in  contact  with  the  two  principal 
branches  just  after  they  leave  the  floor  of  the  skull  and  indirect  or  distal  avulsion. 

A  thorough  knowledge  of  the  regional  anatomy  of  this  part  of  the  subcranial 
space  is  essential,  and  great  care  is  necessary  in  applying  the  remedy. 

Eighty  per  cent  alcohol  is  used  for  the  injection  and  a  special  needle  is  em- 
ployed (Fig.  302).     It  is  sharp  at  the  point  for  penetrating  the  skin  and  dense 


Fig.  302. — Le\'y  and  Baudomn's  needle  with  removable  stylet.      (Hecht.) 

fascia,  and  is  provided  with  a  stylet  which  converts  it  into  a  dull-pointed  instrument 
to  guard  against  wounding  any  vessel  which  may  be  in  the  line  of  penetration. 

Levy  and  Baudouin  give  the  following  technic :  "  For  the  superior  maxillary 
branch,  to  determine  the  point  of  puncture,  a  line  is  drawn  vertically  from  the 
posterior  border  of  the  orbital  process  of  the  malar  bone  to  the  inferior  edge  of 
the  arch  of  the  zygoma.  (See  Fig.  302a.)  The  needle  is  to  be  introduced  at 
a  point  0.5  cm.  posterior  to  this  line  tangentially  measured  on  the  lower  edge  of 
the  zygomatic  arch.  It  is  then  directed  slightly  upward,  and  when  introduced  to 
the  required  depth  of  5  cm.  it  is  well  in  the  pterygo-maxillary  fossa  (Fig.  302&). 

"  At  a  depth  of  2  cm.  a  bony  obstacle  in  the  form  of  an  abnormal  coronoid  process 
may  interfere,  and  still  deeper  an  anomalous  external  pterygoid  plate  may  obstruct. 
In  either  event  the  needle  must  be  inclined  forward,  but  not  too  far,  since  there 
is  danger  of  entering  the  orbit  and  puncturing  the  eyeball.  It  must  also  be  kept 
well  above  the  spheno-palatine  foramen  which  leads  into  the  nasal  fossae.  The 
skin,  cellular  tissues,  anterior  fibers  of  the  masseter  muscle,  and  temporal  tendon 
are  penetrated  in  the  course  of  the  needle. 

"  For  the  inferior  maxillary  branch,  the  point  for  puncture  is  ascertained  on  the 
cheek  by  measuring  off  2.5  cm.  along  the  inferior  border  of  the  zygomatic  arch  in 
front  of  the  descending  bifurcation  of  the  longitudinal  root  of  the  zjgoma.  (Fig. 
302a).  The  needle  inserted  here  to  the  prescribed  depth  of  4  cm.  arrives  at  the 
foramen  ovale  (Fig.  3026)   after  having  passed  through  skin,  siibeutaneous  tissue. 


246     SCALP— SKULL-BRAIN— CRANIAL   NERVES,    SPINAL   CORD    AND    NERVES 

the  zygomatic  insertion,  of  the  masseter,  posterior  portion  of  the  temporal  tendon, 
superior  border  of  the  external  pterygoid  muscle,  and  lastly  in  front  of  the  temporo- 
maxillary   articulation,   which   latter   enables   one   to   avoid   the   transverse   facial 


Fig.  302a. — ir.s.,  Point  of  entrance  for  the  needle  for  penetrating  to  the  superior  maxillary  branch. 
M. I.,  The  inferior  maxillary.      (Hecht.)      ("  Journal  of  the  American  Medical  Association. ") 

artery,  tlie  internal  maxillary  artery  and  veins,  and  the  middle  meningeal  artery 
which  emerges  from  the  foramen  spinosum  "  (Hecht). 

On  account  of  the  danger  to  the  optic  nerve,  the  author  does  not  advise  the 
injection  into  the  ophthalmic  branch. 

The  average  depth  of  penetration  of  tlie  needle  to  reach  the  neighljorhood  of 
the  foramen  ovale  is  4  em.  Ifwould  be  well  to  make  a  part  of  the  injection  at  this 
depth,  withdraw  the  needle  for  a  very  short  distance  {\  cm.)  and  force  out  the 
remainder.  The  quantity  usually  employed  is  from  1  to  2  c.c.  of  eighty  per  cent 
alcohol.  The  strictest  aseptic  precautions  are  essential.  The  patient's  head  should 
rest  easily  on  a  level  plane,  either  sitting  upright  or  lying  on  one  side  of  the  face. 
Local  antesthesia  for  the  skin  is  advised.  The  hand  of  the  operator  should  rest 
firmly  on  the  bones  of  the  face,  and  the  needle  with  the  stylet  slightly  withdrawn 
from  its  tip  is  introduced  to  the  depth  of  about  1  cm.,  when  the  stylet  is  pushed 
forward  and  the  needle  insinuated  to  the  proper  depth.  AVlien  this  is  reached  the 
stylet  is  entirely  withdra'mi  and  the  syringe  containing  the  proper  amount  of 
alcohol  is  attached.  The  contents  should  be  forced  out  rather  slowly,  taking  prob- 
ably as  long  as  a  minute  for  the  entire  injection.  If  the  pain  is  not  entirely  absent 
on  the  succeeding  day,  the  operation  should  be  repeated. 

Hecht  reports  that  except  for  the  cedema  which  followed  the  orbital  injection, 
there  was  not  the  least  unpleasant  effect  after  the  treatment.    As  before  given,  the 


SCALP— SKULL— BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES    247 


author  insists  that  great  caution  is  necessary  in  any  effort  to  inject  the  ophthalmic 
branch  for  fear  of  wounding  the  optic  nerve. 

The  alcohol  renders  the  procedure  aseptic;  furthermore,  it  has  the  peculiarity 
of  relieving  pain  without  giving  sensory  or  motor  paralysis,  or,  if  any,  it  is  slight 
and  temporary.  The  paresis  may  persist  a  few  hours  or  a  few  days;  exceptionally, 
a  few  weeks,  and  rarely  a  few  months.  The  neuralgic  pains  are  sometimes  relieved 
instantaneously  while  the  needle  pricks  the  nerve.  The  rale,  however,  is  that  the 
first  injection  gives  considerable  relief,  but  that  in  severe  neuralgia,  two,  three,  or 
more  injections  must  subsequently  be  given. 

Ostwalt,  of  Paris,  practiced  several  liundred  injections,  the  patients  being 
affected  with  very  severe  neuralgia  dating  back  six,  seven,  nine,  ten,  thirteen,  six- 
teen, and  even  twenty  and  thirty  years.  In  one  third  of  all  patients  there  was  a 
return  of  symptoms  in  four  to  five  months, 
A  few  subsequent  injections,  however,  re-  ,    ,-,. 

lieved  the  neuralgia  permanently.  f^^,    A, 

Should  the  injections  fail,  the  surgeon 
must  choose  between  distal  avulsion  as 
practiced  by  Prof.  Ernest  Laplace,  or  the 
radical  procedure  of  excision  of  the 
ganglion. 

Avulsion  is  confined  to  the  two  infe- 
rior branches  and  the  supra-orbital  fila- 
ments of  the  ophthalmic  division.  The 
superior  maxillary  branch  is  exposed  at 
the  infra-orbital  foramen,  and  without 
being  divided  is  grasped  with  a  delicate 
forceps  which  is  very  carefully  and  slowly 
turned,  winding  the  nerve  as  a  double 
thread  is  wound  upon  a  spool.  So  delib- 
erately must  traction  be  exercised  that 
two  minutes  should  be  taken  for  a  single 
turn,  and  it  takes  from  twelve  to  twenty 
minutes  to  complete  the  f)rocedure.  La- 
place has  succeeded  in  this  way  in  ex- 
tracting practically  all  of  each  division  of 
the  fifth  nerve,  not  only  back  to  the  gan- 
glion, but  removing  with  the  trunk  a  large 
proportion  of  the  anterior  filaments  of 
distribution.  In  'removing  the  inferior 
maxillary  division  the  ramus  of  the  lower 
jaw  must  be  exposed  and  the  canal  opened 
(as  hereafter  described)  for  at  least  one 
inch  of  its  extent.  Plugging  the  canal 
with  sterile  gold-foil  or  a  rubber-tissue 
pack  has  been  recommended  to  prevent  re- 
production and  reunion. 

In  the  event  of  failure  of  these 
methods,  intracranial  '  section  with  re- 
moval of  the  ganglion  of  Gasser  will  be 
necessary. 

Two  operations  are  accepted,  viz. :  the 
osteoplastic  trap-door  flap  of  Hartley  and 

Krause  and  the  bone-sacrificing  procedure  of  Gushing.  In  the  former  a  horse- 
shoe incision  is  made,  the  ends  of  which  are  practically  over  the  outer  and  inner 
ends  of  the  zygoma,  while  its  greatest  convexity  is  from  two  and  one  half  to  three 
inches  above  at  the  temporal  ridge  (Fig.  303). 

The  incision  is  carried  down  to  the  periosteum  in  all  portions  except  one  inch 
above  the  zygoma.  The  divided  soft  tissues  are  retracted,  and  with  a  small  curved 
chisel  a  groove  is  cut  in  the  bone  corresponding  to  the  divided  periosteum  and 


MS 


MI 


Fig.  3026. — Basal  view  of  same.  m.  s.,  Needle 
at  foramen  rotundum ;  M.I.,  Needle  at  fora- 
men ovale.  (Hecht.  "  Journal  of  the  Amer- 
ican Medical  Association.") 


248    SCALP— SKULI^BRAIN— CRANIAL   NERVES,   SPINAL   CORD    AND    NERVES 


Fig.  303.— (After  Hartley.) 


extending  only  to  the  vitreous  plate,  except  at  the  highest  point  of  the  rounded 
portion,  where  the  entire  thickness  of  the  skull  is  removed  sufficiently  to  admit 
the  point  of  an  elevator.  A  periosteal  elevator  is  here  inserted  and  used  as  a  lever 
to  break  the  bone  on  a  line  between  the  "  corks  "  of  the  horseshoe  incision.    In  this 

way  a  "trap-door"  flap,  consisting  of 
skin,  muscle,  periosteum,  and  bone,  is 
turned  down,  exposing  the  dura  mater 
over  a  circular  area  three  inches  in  ex- 
tent. A  catgut  ligature  is  now  thrown 
around  the  middle  meningeal  artery,  the 
dura  carefully  lifted  from  the  bone,  and 
the  floor  of  the  middle  fossa  of  the  skull 
exposed.  Broad  retractors  are  used  to 
lift  the  dura  with  the  brain,  in  order  to 
expose  the  round  and  oval  foramina. 
Any  hsemorrhage  which  occurs  can  be 
stopped  by  pressure.  The  second  and 
third  divisions  of  the  fifth  nerve  should 
now  be  isolated  at  their  respective  fora- 
mina, and  by  slight  pressure  the  dura 
mater  can  be  stripped  from  the  nerve  to 
beyond  the  ganglion  of  Gasser.  With  a 
tenotomy  knife  the  nerve  should  be  cut 
at  the  foramina,  and  that  portion  be- 
tween these  points  and  a  point  on  the 
central  side  of  the  Gasserian  ganglion 
excised.  Care  should  be  taken  not  to 
injure  the  third,  fourth,  and  sixth  nerves, 
which  are  in  close  proximity,  and  also  the  motor  filament  to  the  muscles  of  masti- 
cation which  passes  beneath  the  ganglion  but  is  not  connected  with  it.  A  good- 
sized  catgut  drain  is  put  in  and  allowed  to  come  out  at  the  lower  angle  of  the 
wound.  The  trap-door  flap  of  bone,  muscle,  and  periosteum  is  now  placed  in 
position  and  stitched  with  catgut  sutures.  Hartley  has  used  the  same  method  in 
exploring  the  posterior  fossa,  in  a  case  of  suppurating  meningitis  following  otitis 
media. 

In  this  procedure  an  observation  of  Tiffany  is  of  great  practical  value.  He 
noticed  that,  when  first  opening  the  cranium,  the  brain  entirely  filled  the  cavity, 
and  the  dura  appeared  tense,  due  to  the  presence  of  cerebrospinal  fluid.  He  punc- 
tured the  dvira  and  evacuated  the  fluid,  "  after  which  the  brain  fell  quite  away 
from  the  field  of  operation  and  the  dura  mater  rested,  wrinkled,  on  the  surface  of 
the  brain,  as  a  sheet  loosely  thrown  over  a  bed."  In  removing  the  nerve,  he  begins 
with  the  second  division.  Separating  the  dxira  from  it,  he  passes  a  ligature  around 
it  with  a  long  aneurism  needle  with  a  short  curve,  then  strips  back  the  dura  to 
reach  the  third  division  and  the  ganglion.  A  similar  ligature  is  passed  around 
the  third  division.  With  gentle  traction  upon  the  ligature,  with  a  long,  sharp 
curette  he  separates  the  nerves  and  takes  away  the  adjacent  portion  of  the  ganglion, 
dividing  the  nerves  at  the  round  and  oval  foramina  last.  In  none  of  his  cases  has 
there  been  injury  to  the  third  cranial  nerve,  and  all  recovered.  In  one  case,  four- 
teen months  after  the  operation,  the  anaesthesia  was  disappearing.  The  sense  of 
taste  was  preserved  after  division  of  the  second  and  third  nerves.  Sensations  of 
heat  and  cold  were  appreciable  after  division  of  these  nerves  of  ordinary  sensation. 
He  suggests  the  use  of  the  electrode  to  recognize  and  avoid  section  of  the  motor 
branch  of  the  third  division  of  the  fifth  nerve.  Gushing  has  pointed  out  an  objec- 
tionable feature  of  this  incision,  viz.,  the  division  of  the  filament  of  the  facial  nerve 
which  supplies  the  frontal  portion  of  the  occipito-frontalis  muscle  (Fig.  297). 
He  limits  the  anterior  extent  of  the  curved  incision  through  the  scalp  at  the  hair 
line,  and  thus  avoids  paralysis  of  this  muscle.  From  this  point  in  Cushing's  opera- 
tion "  the  posterior  limb  of  the  incision  is  carried  down  to  the  zygoma  over  the  tem- 
poral vessels,  which  usually  must  be  ligated.    The  skin  fiap  is  then  refiected  down- 


SCALP— SKULL— BRAIN— CRANIAL    NERVES,   SPINAL   CORD   AND   NERVES    249 

ward  and  forward  by  blunt  dissection,  the  handle  of  the  scaliDel  sufficing  for  this 
purpose.  The  temporal  fascia,  thus  exposed,  is  incised  in  a  line  concentric  with 
the  skin  incision  and  likewise  reflected.  The  zygoma,  which  has  been  brought 
into  view  at  the  lower  angle  of  the  wound,  is  shelled  out  of  its  periosteal  sheath, 
not  as  formerly  described  by  making  an  incision  along  its  external  surface,  but 
by  crowding  forward  its  coverings  en  masse.  The  exposed  fibers  of  the  temporal 
may  then  be  divided  as  usual  by  a  horseshoe-shaped  incision,  and  the  muscle  scraped 
away  with  a  periosteal  elevator  as  far  down  as  the  base  of  the  skull.  In  order  to 
satisfactorily  expose  the  skull,  a  little  deeper  retraction  of  the  flap  is  necessary 
than  by  the  older  method,  the  ordinary  small  appendix  retractor  being  used  for 
the  purpose  of  holding  down  the  cutaneous  and  fascial  part  of  the  flap  as  well  as 
the  muscle." 

The  objective  point  in  either  of  these  intracranial  operations  is  the  space  on 
the  floor  of  the  skull  between  the  round  and  oval  foramina,  or  directly  inward  from 
a  point  just  in  front  of  the  eminentia  articularis  or  tiibercle  on  the  posterior  root 
of  the  z3'goma  where  it  fuses  with  the  main  temporal  bone.  The  cranial  surface 
in  this  plane  is  the  thin  squamous  portion  of  the  temporal,  and  through  this  a 
trephine  opening  is  made  which  is  enlarged  with  the  rongeur  sufficient  to  give 
the  necessary  exposure.  The  dura  is  not  divided,  but  may  be  punctured  (Tiffany) 
to  relieve  tension. 

Bleeding  from  the  diploe  may  be  particularly  troublesome,  and  frequently 
necessitates  the  use  of  wax.  Care  must  be  taken  while  biting  away  pieces  of  bone 
from  under  the  muscle  anteriorly,  lest  injury  to  the  meningeal  be  occasioned. 

When  the  bone  is  removed  to  a  sufficient  extent  to  permit  the  unincised  dura 
to  be  lifted  from  the  base  of  the  skull,  this  is  carefully  done  until  the  ganglion  is 
exposed.  Should  the  dura  or  any  blood  vessel  be  torn,  a  temporary  packing  with 
sterile  gauze  will  be  necessary  in  order  to  control  haemorrhage.^  The  branches  of 
the  nerve  will  be  seen  at  their  points  of  exit  at  the  foramen  rotundum  and  foramen 
ovale.  The  second  and  third  branches  should  be  divided  at  the  foramina  and  fol- 
lowed back  to  the  ganglion,  which  is  now  raised  from  its  bed  and  its  connection 
with  the  bone  severed  close  to  the  dura,  if  possible  without  injury  to  the  motor 
root. 

Facial  Paralysis. — As  a  result  of  accident  or  disease,  especially  in  connection 
with  destructive  ostitis  following  infection  of  the  middle  ear,  as  it  passes  through 
the  aquseduetus  Fallopii  to  emerge  at  the  stylomastoid  foramen  the  facial  nerve 
may  be  permanently  impaired.  The  resulting  paralysis  of,  the  muscles  of  ex- 
pression leads  to  such  disfigurement  that  anastomosis  should  be  made  between 
its  distal  end  and  the  proximal  end  of  the  motor  branch  of  the  spinal  accessory 
distributed  to  the  mastoid  and  trapezius  muscles.  "  This  nerve  at  its  exit  from 
the  jugular  foramen  passes  backward  behind  the  jugular  vein  and  descends  ob- 
liquely behind  the  digastric  and  stjdo-hyoid  muscles  to  the  upper  part  of  the  sterno- 
mastoid  "  (Gray). 

The  following  procedure  is  advised  by  Dr.  J.  B.  Murphy : 

"  An  incision  is  made  from  the  anterior  border  of  the  mastoid  process  parallel 
with  the  belly  of  the  digastricus  down  to  the  level  of  the  hyoid  bone.  The  deep 
fascia  is  divided,  hugging  close  to  the  anterior  border  of  the  sternocleido-mastoid 
muscle.  Blunt  scissors  are  employed  in  the  dissection  between  the  digastric  and 
stylohyoid  muscles.  The  spinal  accessory  will  be  found  at  the  upper  angle,  passing 
across  the  field  over  the  tip  of  the  transverse  process  of  the  atlas.  The  hyper- 
glossal  is  just  beneath  the  tip  and  runs  parallel  with  the  digastric  muscle.  Hugging 
the  mastoid  closely,  the  stylomastoid  foramen,  where  the  facial  nerve  makes  its 
exit  as  a  single  trunk,  is  found. 

"  The  parotid  gland  should  not  be  disturbed.  It  is  avoided  by  keeping  close  to 
the  sheath  of  the  sternomastoid  muscle.  The  facial  nerve  is  divided  as  close  to 
the  foramen  as  possible,  the  end  swung  down  and  joined  to  the  end  of  the  com- 

1  In  the  middle  fossa,  the  middle  meningeal  artery  entering  through  the  foramen  spinosum 
grooves  the  floor  of  the  skull  passing  between  the  opening  in  the  cranium  and  the  foramina  ovale 
and  rotundum  about  a  half  inch  from  the  former  and  three  fourths  of  an  inch  from  the  latter. 
It  is  the  principal  obstacle  to  a  dry  dissection. 


250     SCALP— SKULL— BRAIN— CRANIAL    NERVES,   SPINAL   CORD    AND    NERVES 

pletely  divided  spinal  accessory  by  a  paraneural  (No.  0)  catgut  suture.  An  ex- 
ceedingly delicate  half-curve  round  needle  should  be  carefully  passed  into  the 
nerve  sheath  about  one  eighth  of  an  inch  from  the  cut  end.  Every  effort  should 
be  made  to  avoid  piercing  the  nerve  substance.  For  protection,  the  point  of  union 
should  be  imbedded  in  the  belly  of  the  sterno-hyoid  muscle,  and  completely  hidden 
from  view  b}^  a  few  stitclies  of  catgut." 

As  a  dry  dissection  greatly  facilitates  this  delicate  operation,  should  bleeding 
be  annoying  Dawbarn's  sequestration  should  be  practiced.  An  adrenalin  may  be 
employed. 


CHAPTEE    XII 


Wounds  of  the  eyelids  and  of  the  circular  muscle  should  be  thoroughly  disin- 
fected by  the  careful  use  of  frann  salt  solution  and  1-5000  mercuric-chloride  solu- 
tion. Any  irritating  effects  from  the  mercuric  solution  upon  the  conjunctiva  or 
cornea  may  be  neutralized  Ijy  dropping  plain,  warm  water  under  the  lid.  Prelimi- 
nary cocainization  by  instilling  five  or  si.x;  drops  of  two-per-cent  solution  will 
prevent  pain.  Hemorrhage  may  usually  be  controlled  1>y  suture.  When  the  orbicu- 
laris miiscle  is  severed  the  ends  should  be  carefully  approximated.  If  the  lids  are 
divided,  the  sutures  should  be  of  horsehair  or  the  finest  linen,  and  jjassed  through 
all  of  the  tissues  of  the  lid  close  to  the  margins  of  the  incision.  In  order  to  prevent 
a  nick  at  the  palpebral  margin  a  short  lateral  incision  may  be  made,  as  in  the 
operation  to  correct  this  deformity  in  harelip. 

Contusions  about  the  eye  should  be  treated  by  cold  applications,  using  a  light 
ice-bag  or  soft  linen  cloth  or  gauze  taken  from  ice. 

New  Formations. — Vascular  new  growths,  usually  of  the  capillary  variety,  are 
occasionally  situated  near  the  eye  and  involve,  as  a  rule,  the  muco-cutaneous  Ijorder. 

They  may  be  treated  by  injection  of  boiling  water,  as  advised  for  these  neo- 
plasms elsewhere.  More  than  ordinary  care  should  be  taken  to  prevent  a  possi- 
laility  of  leakage  of  the  hot  water  into  the  eye  or  upon  the  skin.  Kot  more  than 
five  to  ten  drops  should  be  injected  at  one  sitting. 

Capillary  angeioma,  on  account  of  the  absence  of  an  epidermal  covering,  is  apt 
to  break  down  and  become  infected,  resulting  in  the  formation  of  scar  tissue. 
This,  following  repeated  injections,  reduces  the  size  of  the  area  formerly  occu- 
pied by  the  new  growth,  and  as  soon  as  all  the  dilated  vessels  have  disappeared, 
the  resulting  scar  may,  if  deemed  necessary,  be  removed  by  dissection.  It  is  usually 
more  satisfactory  to  close  the  open  wound  by  sliding  and  stretching  the  integument. 

As  the  palpebral  artery  runs  just  beneath  the  skin  of  the  eyelid  about  one 
eighth  of  an  inch  from  the  free  border,  an  incision  should  not  cross  this  line  unless 
it  is  absolutely  necessary. 

Warts  or  cutaneovs  horns  on  the  lid  should  be  clipped  off  with  the  scissors. 
Small  tumors  filled  with  sebaceous  matter  occurring  here  (molluscum  contagiosum) 
should  be  incised  and  the  contents  squeezed  out.  Wlien  near  the  palpebral  mar- 
gin infection  not  infrequently  occurs,  forming  a  sty  or  hordeolum.  The  treatment 
is  puncture  with  a  sharp,  clean  Imife,  and  the  removal  of  the  contents  by  pressure 
or  curettage.  Professor  Webster  recommends  sulphide  of  calcium  (gr.  ss.)  twice 
each  day  as  a  cure  and  preventive. 

Cysts  connected  with  the  eyelids,  either  upon  the  mucous  or  cutaneous  sur- 
faces, often  require  complete  removal  of  the  sac  to  effect  a  cure. 

Epitheliomata  may  be  cured  by  the  application  of  Marsden's  paste  even  wlien 
they  involve  the  free  border  of  the  lid.  Careful  attention  will  prevent  the  irritation 
of  the  conjunctiva  by  arsenious  acid. 

Obstructions  of  the  ducts  of  the  Meibomian  glands  (chalazion)  are  indicated 
by  redness  and  swelling  of  the  conjunctiva  along  the  surface  of  the  tarsal  cartilage. 
They  sliould  be  treated  by  puncture  through  the  edge  of  the  lid  with  evacuation 
of  their  contents  by  pressure  upon  both  surfaces  of  the  lid  directly  toward  the 
free  border.  In  obstinate  cases  a  thorough  curetting  of  the  walls  of  the  sac  ren- 
ders a  recurrence  less  liable.    Any  incision  on  the  under  surface  of  tlie  lids  should 

251 


252 


THE   EYE 


be  made  at  right  angles  to  the  free  border.     On  the  outer  cutaneous  surface  the 
incision  should  be  parallel  with  this  border. 

A  rare  form  of  cystic  tumor  occasionally  develops  in  the  substance  of  the  tarsal 
cartilage.  It  may  be  cured  by  incision  with  removal  of  the  sac  or  by  burning 
with  a  drop  of  pure  carbolic  acid,  carefully  guarding  against  contact  of  the  cornea 
with  this  substance. 

Blepharitis  or  inflammation  of  the  lids  may  affect  all  or  a  limited  portion  of 
these  organs.  It  most  frequently  involves  the  ciliary  margins,  and  is  known  as 
blepharitis  ciliaris.  In  rare  instances  the  cartilages  are  involved.  Acute  hlepharitis 
demands  rest  and  local  antiphlogistic  applications.  Cloths  dipped  in  warm  water 
are  in  general  more  agreeable.  In  chronic  hlepharitis  ciliaris  the  scaly  covering 
of  the  inflamed  borders  of  the  lids  should  be  removed  by  the  prolonged  use  of 
warm  boric-acid  water  and  a  mop  of  soft  lint,  having  first  trimmed  the  lashes 
closely.  When  this  is  done  the  inflamed  surface  should  be  lightly  touched  with 
a  pencil  of  lunar  caustic.  At  night  the  lids  should  be  lubricated  with  a  small 
quantity  of  cosmoline. 

WTien  removal  of  the  eyelashes  {epilation)  becomes  necessary,  they  should  be 
grasped  with  broad-ended  forceps  which  have  finely  roughened  blades,  and  removed 
by  pulling  gently  and  carefully  in  the  normal  axis  of  the  lash.  Lateral  movements 
tend  to  break  the  hairs  and  leave  the  stubs  in  situ. 

Blepharospasm,,  or  spasm  of  the  orbicularis  palpebrarum  muscle,  results  usu- 
ally from  irritation  of   the  conjunctiva   or   cornea.      It  may,    in  rare  instances, 

occur  without  any  inflammatory  exciting 
cause  (idiopathic  blepharospasm).  The 
treatment  is  rest  and  the  removal  of  the 
cause  of  the  spasm.  In  rare  cases  divi- 
sion of  the  muscle  through  the  outer  can- 
thus  (canthoplasty)  is  demanded  to  re- 
lieve pressure  on  the  conjunctiva,  cornea, 
and  globe. 

Blepharophimosis,  or  narrowing  of  the 
palpebral  opening,  is  due  to  contraction 
of  the  lids  at  the  outer  canthus  or  angle. 
It  may  be  relieved  by  an  incision  com- 
mencing in  the  outer  angle  and  carried 
directly  out  through  the  entire  thickness 
of  the  commissure  for  the  required  dis- 
tance, extending  the  cut  in  the  skin  a 
short  distance  farther  than  that  in  the 
conjunctiva.  The  edges  of  the  skin  and 
mucous  membrane  are  then  united  by  silk 
sutures,  as  shown  in  Fig.  304. 
Lagophthalmos. — Inability  to  close  the  eyelids  may  be  due  to  protrusion  of  the 
globe  from  tumors  of  the  orbital  cavity,  or  of  the  globe;  it  occurs  in  the  disease 
of  which  enlargement  of  the  thyroid  body  and  "  exophthalmos  "  are  symptoms ;  in 
staphyloma  and  in  paralysis  of  the  facial  nerve.  It  is  a  serious  condition,  on 
account  of  the  liability  of  ulceration  of  the  cornea  from  prolonged  exposure  of 
the  anterior  surface  of  the  globe.  The  indications  in  treatment  are  first  palliaiive 
in  keeping  the  lids  closed  by  bandaging,  or  uniting  the  edges  by  sutures.  When 
the  condition  is  permanent,  the  operation  of  tarsorrhaphy  is  to  be  performed  as  fol- 
lows :  Introduce  a  horn  spatula  between  the  globe  and  the  lids  at  the  outer  canthus ; 
make  the  tissue  tense,  and  with  a  sharp  loiife  remove  the  free  borders  of  the 
upper  and  lower  lid  for  a  distance  sufficient  to  close  the  eye  to  the  desired  extent. 
The  incision  should  remove  the  roots  of  the  cilite.  Tlie  opposing  edges  are  now 
united  with  silk  sutures. 

Blepharoptosis. — Ptosis,  or  inability  to  lift  the  upper  lid,  may  be  due  to  partial 
or  complete  paralysis  of  the  third  nerve,  or  the  filament  which  supplies  the  levator 
palpebrfe ;  to  adhesions  from  inflammatory  affections  of  the  lid ;  to  the  presence 
of  neoplasms  or  to  acquired  or  congenital  weakness  of  the  levator  muscle.     Ptosis 


Fig.  304. — Incision  and  sutures  in  operation  for 
blepharopliimosis.     (De  Wecker.) 


THE   EYE 


253 


due  to  paralysis  may  be  corrected  by  excising  an  elliptic-shaped  piece  of  the  skin 
of  the  upper  lid,  including  the  areolar  tissue  and  the  fibers  of  the  orbicular  muscle. 
The  lower  iucision  should  run  parallel  with  the  margin  of  the  lid  and  about  one 
quarter  iach  above  it.  -  The  edges  of  the  two  incisions  should  be  united  with  silk 
sutures. 

Should  this  operation  not  prove  satisfactory,  the  procedure  of  Bverbusch  may 
be  tried.  The  tendon  of  the  levator  palpebrse  is  freely  exposed  by  an  incision 
at  the  base  of  the  tarsal  cartilage,  and  the  tendon  shortened  by  inserting  three 
ten-day  catgut  sutures  so  as  to  loop  it  upon  itself;  or  the  procedure  of  Wolff, 
which  resects  a  piece  of  the  levator  tendon  and  reunites  the  cut  end  to  the  upper 
border  of  the  tarsus,  may  be  substituted.  It  is  advisable  to  proceed  cautiously,  since 
overcorrection  is  to  be  avoided. 

Symblepliaron  is  a  term  applied  to  adhesions  of  the  lids  to  the  ocular  conjunc- 
tiva.    Limited  adhesions  may  be  broken  up  repeatedly  until  a  cure  is  effected  by 


Fig.  305. 
Symblepharou.  A,  Incision 
through  the  attached  con- 
junctiva at  the  comeo- 
sclerotic  junction.  Teale's 
operation.      (Swanzy.) 


Fig.  306. 
The  same.  T>,  Adherent  con- 
junctiva dissected  dow'n. 
-B,  C,  Incision  for  flaps  to 
cover  this  wound.  (Swan- 
zy.) 


Fig.  307. 
The  same.  A,  Tip  of  sym- 
blepliaron left  to  disappear 
by  absorption.  C,  B,  Flaps 
turned  and  sewed  into  new 
position.  D,  E,  Wounds 
closed  by  sutures.  (Swanzy.) 


the  extension  of  an  epithelial  covering  over  the  granulating  surfaces.  Wlien  the 
adhesions  are  extensive,  Teale's  operation  may  be  jJerformed.  Supposing  the  con- 
dition shown  in  Fig.  305  to  exist,  the  symblepharon  is  cut  through  at  A,  in  the 
line  of  the  corneo-sclerotic  junction,  and  the  lid  is  dissected  up  to  the  normal 
fold  of  palpebral  and  ocular  conjunctiva  {D,  Fig.  306).  Two  flaps  {B  and  C, 
Fig.  306)  are  now  dissected  up  from  the  conjunctiva  and  turned  down  and  stitched 
in  position  to  cover  the  raw  surface  left  by  the  dissection  of  the  adhered  lid.  The 
spaces  left  by  lifting  the  flaps  are  closed  at  once  by  fine  silk  sutures  (Fig.  307). 
The  island  of  tissue  left  on  the  cornea  is  allowed  to  disappear  by  atrophy. 

Ectropion,  or  eversion  of  the  lid,  may  be  partial  or  complete,  and  is  due  first 
to  weakness  of  the  orbicularis  palpebrse  muscle,  especially  to  the  palpebral  fibers; 


{  ^ 


Fig.  308. — ^Wharton  Jones'  operation  for  ector- 
pion  of  the  lower  lid.      (De  Wecker.) 


Fig.  309. — ^The  same,  after  the  flap  is  dissected 
up  and  the  sutures  tied.     (De  Wecker.) 


second  to  cicatricial  contractions  due  to  injury  or  disease  of  the  soft  parts  above 
the  eye,  or  of  the  bones  surrounding  the  orbital  cavity.  The  lower  lid  is  usually 
involved. 


254 


THE   EYE 


The  milder  cases  may  be  relieved  by  repeated  cauterizations  of  the  conjunctiva 
with  the  nitrate-of-silver  stick  or  the  carefully  used  electrical  cautery  along  the 
lid  border.     If  this   treatment  does  not   succeed,   and  deep   cicatricial   adhesions 

have   occurred,   Wharton   Jones'    V   Y 

operation  may  be  adopted. 

As  shown  in  Fig.  308,  a  V-shaped 
incision  is  made  so  as  to  include  the 
sear,  the  flap  dissected  up,  and  the  un- 
derlying cicatricial  adhesions  cut  out. 
The  lid  is  lifted  into  its  normal  posi- 
tion, stitched  to  its  upper  fellow,  if 
necessary,  to  hold  it  in  place,  and  the 
edges  of  the  wound  sutured  from  be- 
low upward,  leaving  a  Y-shaped  scar 
(Fig.  309). 

In  more  extensive  adhesions  (Fig. 
310),  in  which  neither  of  the  fore- 
going methods  will  meet  the  indica- 
tions, a  plastic  operation  is  inevitable. 
Make  one  incision,  parallel  with  the 
free  border  of  the  lid,  which  shall  ex- 
tend beyond  the  cicatricial  tissue  to  be 
removed.  Dissect  out  freely  all  adhe- 
sions and  cicatricial  material  until, 
when  left  to  itself,  the  remaiaing  edge 
of  the  lower  lid  rises  into  its  natural 
position.  In  order  to  fill  the  deep  oval 
cavity   (Fig.  311)   left  by  such  dissec- 

^___  tion,  a  flap  may  be  turned  from  the 

cheek,  forehead,  or  arm.  The  plan  of 
the  flap  from  the  cheek  is  shown  in  Fig.  312.  It  should  be  cut  by  measurement, 
so  as  to  fit  without  tension.  As  soon  as  it  is  turned  across  to  its  new  position, 
the  eyelids  should  be  stitched  together,  and  the  flap  accurately  and  carefully  sutured 


Fig.  310. — Complete  ectropion  of  lower  lid,  due  to 
cicatricial  contractions  after  ostitis  of  the  orbital 


Fig.  311.^ — Showing  the  cicatricial  tissue  di^'sected  out,  and  the  flap  to  be  turned  from  the  cheek 

outlined 


to  the  margins  of  the  elliptical  wound.  Before  the  lower  row  of  sutures  is  inserted, 
the  edges  of  the  perpendicular  wound  from  which  the  flap  was  removed  should  be 
approximated  by  sutures  of  fine  silk,  which  material  should  be  used  throughout. 


THE   EYE 


255 


The  stitches  are  to  be  removed  about  the  fifth  daj'.  If  any  puSing  remains  at  the 
seat  of  the  pedicle  of  the  flap,  it  may  be  relieved,  after  a  few  months,  by  dissecting 
out  a  small  elliptical  piece  and  bringing  the  edges  together. 

When  the  cavity  from  which  the  flap  has  been  taken  cannot  be  entirely  closed 
by  suture,  small  Thiersch  grafts  should  be  employed  to  prevent  a  broad  cicatrix. 


Fig.  312. — The  flap  stitched  into  position,  and  the  wound  formed  by  its  removal  closed.     The  lids  tem- 
porarily sutured. 

Entropion,  or  inversion  of  the  lid,  usually  results  from  chronic  inflammation 
of  the  conjunctiva  and  tarsal  cartilage.  It  is  more  frequent  in  the  upper  lid.  In 
mild  cases  relief  may  be  obtained  by  epilation,  or  by  splitting  the  edge  of  the  lid 


Fig.  313. — Knapp's  entropion  forceps,  or  clamp. 


and  destroying  the  hair  follicles,  or  by  excising  an  elliptical  strip  of  the  integument 
of  the  lid  and  stitching  the  edges  of  the  wound  together.  When  the  tarsal  cartilage 
is  involved,  Snellen's  method  will  prove  more  satisfactory. 

With  EjQapp's  clamp  applied,  make  an  incision  through  the  skin  one  eighth 
of  an  inch  from  and  parallel  with  the  whole  length  of  the  margin  of  the  lid.    Lift 


Fig.  313a. — Lid  scalpels. 

the  sMn-flap,  expose  the  fibers  of  the  orbicularis  muscle,  and  excise  a  strip  of  the 
muscle  about  one  twelfth  of  an  inch  wide  for  the  full  length  of  the  incision.  The 
tarsal  cartilage  is  now  seen,  and  from  it  as  far  as  it  is  exposed  a  wedge-shaped  piece 
is  excised  with  a  sharp  knife  (Fig.  314).  The  apex  of  the  wedge  points  toward 
the  conjunctiva,  but  the  section  i^hould  not  extend  entirely  through  the  cartilage. 


256 


THE   EYE 


Three  sutures  are  now  inserted,  each  entering  from  without  inward,  traversing  the 
skin  and  muscle  (Fig.  315)  of  the  strip  left  at  the  palpebral  margin;  then  in  the 
same  direction  it  is  carried  across  the  wound  into  the  upper  bevel  of  the  incision 
in  the  cartilage,  from  which  it  emerges  (without  transfixing  the  integument  of 
the  flap),  to  be  again  brought  out  through  the  tissues  it  first  entered,  about  one 
eighth  of  an  inch  distant  from  the  pomt  of  entrance.     Each  end  of  the  suture 

is  fastened  with  a  shot,  to  prevent  it 

cutting  through. 


Fig.  314. — Perpendicular  section  sliowin^  char- 
acter of  dissection.  The  muscular  strip  and 
a  triangular  strip  of  the  tarsal  cartilage  are 
removed.      (De  Wecker.) 


Fig.  315. — Front  view  of  the  same,  with  sutures 
inserted  ready  to  be  tied.    "(De  Wecker.) 


Trichiasis,  or  turning  in  of  the  eyelashes,  occurs  with  entropion,  but  may  exist 
independently'.  Occurring  with  inversion  of  the  lid,  it  does  not  require  any  other 
interference  than  that  given  for  the  cure  of  entropion.  Wlien  the  ciliffi  turn  in 
without  inversion  of  the  lid,  the  proper  method  of  treatment  is  total  excision  of 
the  hair  follicles.  This  should  be  accomplished  by  two  parallel  incisions  made 
along  the  margin  of  the  lid,  one  on  either  side  of  the  row  of  hairs,  and  extending 
deep  enough  to  insure  the  complete  removal  of  the  roots  of  the  ciliae.  When  only 
a  few  hairs  are  at  fault,  the  follicles  may  be  destroyed  by  the  galvanic  needle. 


Fig.  316. — Gruening's  depilating  forceps. 

When  depilation  is  demanded,  the  instrument  shown  in  Fig.  316  will  be  found 
of  great  service.  In  distichiasis  there  is  an  extra  row  of  ciliae ;  these  require  removal 
by  the  method  just  given. 

Eczema  of  the  eyelids  is  not  of  very  frequent  occurrence.  Swanzy  recom- 
mends the  daily  removal  of  the  crusts  by  bathing  the  jiarts  in  a  warm  solution 
of  bicarbonate  of  potash,  drying,  and  then  painting  with  solution  of  nitrate  of 
silver  (gr.  xx  to  water  gj) ;  after  this  an  ointment  of  boracic  acid  (gr.  xsx  to  §j) 


Epicanthus. — This  term  is  applied  to  a  congenital  defect  which  consists  of 
a  fold  of  skin  stretched  across  the  inner  canthus  and  the  caruncula.  It  may 
be  relieved  by  excising  an  elliptical  piece  of  integument  in  the  long  axis  of 
the  nose  Just  between  the  eyes.  The  width  of  the  excised  portion  must  be  suffi- 
cient to  remove  the  deformity  when  the  edges  of  the  wound  are  drawn  together 
hj  sutures. 

Restoration  of  the  Eyelids. — In  destruction  of  the  lids  by  accident  or  disease 
it  becomes  necessary  to  restore  the  covering  to  the  globe.  Flaps  may  be  turned 
from  the  neighboring  healthy  integument  or  borrowed  by  a  plastic  operation 
from  the  arm.  In  many  eases  much  damage  may  be  prevented  by  applying 
good-sized  and  numerous  grafts  to  the  exposed  surfaces  while  granulation  is 
ffoinff  on. 


257 


The  LACHETiTAL  GlaisT)  A^-D  Ducts 


Disease  of  the  lachrymal  gland  is  rare.  In  inflammation  of  this  organ  (dacryo- 
ade/iitis)  tenderness  and  s-n-elling  may  be  observed  in  the  upper  outer  portion  of 
the  orbital  cavity.  In  well-marked  enlargement  from  any  cause,  the  eyeUd  is 
pushed  for-svard  and  the  globe  displaced  downward  and  inward.  An  abscess  here 
should  be  opened  by  puncture  through  the  base  of  the  lid  at  the  most  convenient 
point.  "WTien  a  neoplasm  develops  in  the  gland,  extirpation  should  be  done  by 
incision  in  the  fold  of  the  upper  lid,  Just  beneath  the  brow. 

Epipliora,  or  continual  overflow  of  tears,  is  caused  by  obstruction  in  the  system 
of  canals  which  normally  should  conduct  the  secretion  of  the  lachr}-mal  gland  from 
the  margins  of  the  lids  into  the  nasal  cavity,  or  by  displacement  of  the  puncium 
lachrymale.  so  that  the  tears  cannot  enter  the  orifice.  On  account  of  its  position, 
the  lower  canaliculus  is  of  much  more  importance  to  the  drainage  of  the  eye  than 
the  upper. 

Epiphora  due  to  disturbance  of  the  canaliculus  may  be  present  as  a  s^-mptom  of 
any  displacement  of  the  lower  lid,  from  swelling,  paralysis,  or  cicatricial  contrac- 
tion, the  direction  of  the  puncture  being  so  changed  that  neither  gravity  nor  the 
normal  suction-force  will  carry  the  secretion  into  the  opening.  Occlusion,  partial 
or  complete,  may  occur  either  from  lodgment  of  foreign  substances,  products  of 
inflammation,  pus,  epithelia,  etc.,  and  occasionally  to  calcareous  formations  {da- 
cryoliths) . 

The  most  common  form  of  obstruction  is,  however,  met  with  in  the  nasal  por- 
tion of  the  excretory  apparatus.  Catarrhal  inflammation  of  the  mucous  mem- 
brane lining  the  canal  or  cyst  may  occlude  the  duct  either  by  approximation  of  the 
walls  or  by  excessive  secretion  of  tenacious  mucus.  Such  condition  is  met  with  in 
patients  of  all  ages,  occurring  chiefly  in  the  poorly  nourished  and  scrofulous  or 
tuberculous  subjects,  who  suffer  from  chronic  nasal  catarrh  and  ophthalmia,  or 
ostitis  of  the  neighboring  bones.  As  a  result  of  obstruction  in  the  nasal  duct, 
dacryo-cystiiis,  or  inflammation  of  the  lachrymal  sac,  may  ensue  with  distention, 
the  swelling  showing  beneath  the  skin  at  the  inner  angle  of  the  eye  [mucocele). 

~G.TIEMArv'M»Ca. 

Fig.  317. — Agnew's  canalicula  knife. 

The  treatment  of  displaced  punctum  lachrymale  should  be  directed  to  the  res- 
toration of  the  lid  to  its  normal  position.  In  partial  obstruction,  due  to  catarrhal 
conditions,  relief  may  be  obtained  by  slitting  the  canal  with  the  canaliculus  knife 
or  scissors,  and  frequently  repeated  irrigations  with  the  lachr^Taal  syringe.  When 
obstruction  occurs,  dilatation  by  means  of  probes  is  indicated.  Should  the  stric- 
ture be  close  and  resisting,  the  knife  should  be  carefully  introduced  and  a  division 
effected,  the  dilatation  being  continued  by  inserting  the  probes  at  intervals  of 
two  to  six  days.  The  prognosis  in  many  cases,  no  matter  how  faithfully  and  skill- 
fully treated,  is  not  favorable. 

In  slitting  iip  the  canaliculus  the  delicate  probe-pointed  knife  or  scissors  should 
be  introduced  at  the  inferior  punctnm.  and  carried  toward  the  canthus  for  a  dis- 


FiG.  318. — Theobold's  lachrj-mal  probes. 

tanee  of  about  one  sixth  of  an  inch,  the  slit  extending  for  this  distance.  The 
wound  should  be  kept  open  by  forcibly  separating  the  edges  once  or  twice  a  day, 
imtil  the  cut  surfaces  are  covered  witli  epithelium  and  the  trough  becomes  perma- 


258 


THE   EYE 


nent.  Some  operators  in.  chronic  dacryo-cystitis  prefer  to  slit  the  upper  canaliculus 
and  pass  the  probes  by  this  route.  The  bulb-pointed  dilating-probes  should  now 
be  carefully  introduced,  beginning  with  the  smaller  sizes  (Fig.  318).  As  soon  as 
the  bulb  enters  the  sac,  it  should  be  gently  and  slowly  directed  along  the  nasal  duct 
until  it  is  arrested  by  the  floor  of  the  nose.  The  larger  sizes  may  be  introduced 
as  in  the  treatment  of  stricture  of  the  urethra.     After  full  dilatation  is  secured 


Fig.  319. — Anul's  ."^yringe. 


the  channel  should  be  washed  out  daily,  for  about  ten  days,  with  a  one  per  cent 
boracic-acid  solution.  Por  this  purpose  Anel's  syringe  (Fig.  319)  will  be  found 
useful.  The  probe-pointed  nozzle  is  introduced  into  the  sac  and  the  water  forced 
through  until  it  flows  freely  into  the  nose.  If  the  obstruction  recurs,  the  probes 
should  be  reintroduced  at  regular  intervals,  gradually  increasing  until  a  perma- 
nent opening  is  effected. 

The  Conjunctiva  and  Cornea 

Conjunctivitis  may  be  acute  or  chronic,  and  circumscribed  or  diffuse.  Simple 
conjunctivitis  may  result  from  prolonged  strain  or  overuse  of  the  eyes,  from  the 
lodgment  of  foreign  particles,  or  exposure  to  strong  winds.  The  hypersemia  may  be 
confined  to  a  limited  portion  of  the  mucous  membrane,  or  spread  over  the  entire 
palpebral  and  ocular  conjunctiva. 

The  treatment  consists  in  the  instillation  of  two  or  three  drops  of  cocaine,  two 
to  four  per  cent  solution,  at  intervals  of  from  one  to  several  hours,  the  removal  of 
any  foreign  matter,  rest  by  closure  of  the  lids,  or  the  dark  room  and  the  application 
of  soft  cloths  taken  from  cold  boracic^acid  solution  (grs.  x  to  §j)  or  from  a  block 
of  ice. 

Follicular  conjunctivitis  may  follow  an  acute  simple  inflammation,  and  is  char- 
acterized by  the  develojmaent  of  small  red  points  or  elevations  scattered  over  the 
deeper  portions  of  the  palpebral  surfaces  of  the  mucous  membrane  and  the  con- 
tiguous reflection  of  the  ocular  conjunctiva.  The  elevations  are  swollen  and  dis- 
tended lymphatic  channels  and  follicles.  The  disease  is  characterized  by  con- 
siderable pain,  inability  to  use  the  eyes,  and  a  sensation  as  if  a  gritty  or  sandy 
substance  were  present.  In  treatment  the  condition  of  the  general  system  should  be 
improved  by  tonics  and  nutritious  diet;  rest  to  the  dis- 
eased organs,  and  the  daily  application,  by  means  of  a 
camel's-hair  brush,  into  the  conjunctival  sac  of  a  small 
mass,  about  one  eighth  inch  diameter,  sulphate  of  copper 
gr.  ss.  to  ij  in  5j  vaseline  (Swanzy). 

Granular  Conjunctivitis  {Trachoma). — It  is  not  j'et 
positively  known  whether  there  is  any  real  pathological 
difference  between  follicular  and  granular  disease  of 
the  conjunctiva.  Trachoma  is  chiefly  met  with  among 
the  poorly  fed,  who  live  in  unwholesome  surroundings. 
It  is  held  to  be  contagious  at  all  times,  and,  when  a 
muco-purulent  discharge  is  plentiful,  the  contagious  nature  of  the  aifection  is 
evident. 

In  the  earlier  stages  there  appear  upon  the  lower  lid  round,  granular  elevations, 
scattered  here  and  there,  or  the  whole  mucous  membrane  may  be  thickly  studded. 
As  a  result  of  the  chronic  inflammation  the  lid  is  at  first  thickened.    As  the  process 


Fig.  320. — Granular  lower 
lid.     (Eble.) 


THE  EYE  259 

is  continued,  the  usual  cicatrization  and  contraction  results,  causing,  in  obstinate 
cases,  deformities  of  the  lids  and  great  and  persistent  discomfort. 

The  treatment  includes  the  measures  just  given  for  follicular  conjunctivitis. 
In  addition,  either  the  sulphate-of -copper  stick  or  nitrate  of  silver  in  strong  solution 
— grs.  x-xx  to  5j — or  the  mitigated  lunar  caustic.  Nettleship  advises  the  follow- 
ing strength :  "  Xitrate  of  silver,  one  part ;  nitrate  of  potash,  two  parts,  fused  to- 
gether and  run  into  molds  to  form  short  pointed  sticks;  used  for  granular  lids 
and  purulent  ophthalmia."  Applied  daily,  or  less  frequently,  as  may  be  demanded. 
When  these  measures  fail,  canthoplasty  may  be  done  and  the  diseased  tissue  dis- 
sected from  the  lids. 

In  both  varieties  of  trachoma  the  cure  is  greatly  accelerated  by  the  operation 
of  expression,  or  squeezing  out  the  contents  of  the  granular  elevations  by  means  of 
Prince's  forceps.  More  can  be  accomplished  by  this  operation  when  done  thoroughly 
than  by  any  other  method  of  treatment  (Webster). 

Gonorrhceal  Ophthalmia. — Conjimctivitis  caused  by  the  introduction  of  the  virus 
of  gonorrhoea  into  the  ej^e  should  be  treated  with  great  care  and  persistency  from 
the  first  symptom  of  this  painful  affection.  Usually  a  single  organ  is  attacked. 
It  is  important  that,  while  the  effort  to  cure  one  eye  is  being  made,  the  other 
should  be  protected  from  the  contagion.  To  effect  this,  a  watch  glass,  to  the  edge 
of  which  adhesive  plaster  is  attached,  is  placed  over  the  sound  eye  and  closely  fas- 
tened to  the  skin  about  the  orbit  by  the  plaster,  so  that  it  is  hermetically  sealed. 
This  should  not  be  removed  until  the  other  eye  is  well. 

In  the  local  treatment  of  the  affected  eye  it  is  required  to  remove  the  purulent 
discharge  by  frequent  irrigation  with  warm  boracic-acid  water  or  by  the  pellets 
of  lint  or  absorbent  cotton,  and  to  brush  over  the  everted  lids  once  or  twice  a  day, 
as  the  attack  is  light  or  severe,  a  solution  of  nitrate  of  silver  (grs.  xx  to  §j).  The 
excess  shoirld  be  immediately  washed  off  with  tepid  water.  Cold  applications  are 
of  great  importance,  and  a  very  efficient  method  is  to  apply  frequent  changes 
(every  one  or  two  minutes)  of  pieces  of  lint  about  two  inches  square,  which  are 
taken  directly  from  a  block  of  ice  and  laid  over  the  inflamed  organ.  In  this  form, 
of  conjunctival  inflanmiation,  as  in  others  where  the  injection  is  marked  and  the 
tliickening  great,  and  where  painful  blepharospasm  occurs,  or  where  a  free  dis- 
charge of  purulent  matter  cannot  be  effected  )jy  ordinary  means,  canthoplasty  is 
required.  This  operation  consists  in  slitting  the  outer  canthus  in  the  direction 
of  the  ear,  and  in  this  way  dividing  the  fibers  of  the  orbicular  muscle. 

In  gonorrhceal  conjunctivitis  the  impairment  of  function  in  the  muscle  is  not 
intended  to  be  of  long  duration,  and  the  wound  is  left  open.  In  some  cases  of 
spasm  of  this  muscle,  and  where  a  chronic  inflammation  exists,  the  mucous  mem- 
brane is  stitched  to  the  skin  along  the  edges  of  the  wound,  thus  preventing  a 
reunion.  Eeunion  may  be  efllected  later  by  paring  the  edges  and  bringing  the 
parts  together  after  the  lesion  for  which  the  canthoplasty  was  performed  is  healed. 
Cocaine  should  be  used  to  relieve  pain,  and  all  adhesion  between  the  ocular  and 
palpebral  mucous  surfaces  should  be  broken  up  as  soon  as  discovered. 

Conjunctivitis  in  the  newborn  (ophthalmia  neonatorum)  is  a  form  of  purulent 
ophthalmia  which  usually  results  from  the  inoculation  of  the  conjunctiva  with  septic 
matter  j^resent  in  the  genital  passages  of  the  mother.  It  may  come  from  carelessness 
on  the  part  of  the  nurse,  herself  affected  with  a  leucorrhoea,  etc.,  or  from  the  lodg- 
ment of  any  virus  in  the  eye  of  the  child.  The  treatment  is  prophylactic  as  well  as 
curative. 


The  eyes  of  a  child  born  of  a  mother  known  to  be  suffering  from  a  vaginal  dis- 
charge of  a  purulent  character  should,  as  soon  as  possible  after  birth,  be  washed 
or  mopped  out  with  clean  warm  water,  or  boracic-acid  solution,  to  be  followed  with 
one  or  two  drops  of  a  two  per  cent  nitrate-of-silver  solution  (grs.  x-gj)  once  or 
twice  a  day,  for  three  or  four  days. 


260  THE  EYE 

The  pus  should  be  gently  removed  by  pellets  of  absorbent  cotton,  dipped  in  warm 
boracic-acid  solution,  the  lids  everted,  and  nitrate-of -silver  solution  (grs.  v-x  to  §j) 
applied  to  the  inflamed  surfaces  by  means  of  a  camel's-hair  brush.  The  excess 
should  be  immediately  washed  away  by  the  free  use  of  warm  water.  This  should 
be  repeated  every  day  until  the  purulent  discharge  is  notably  diminished. 

The  eyes  should  be  carefully  cleansed  with  warm  solution  of  boracic  acid  every 
half  hour  day  and  night,  or  as  often  as  any  secretion  appears  between  the  edges  of 
the  eyelids. 

Croupous  conjunctivitis  is  a  contagious  disease  met  with  in  children,  and  char- 
acterized by  injection  of  the  mucous  membrane  and  the  deposit  of  a  film  or  mem- 
brane upon  the  conjunctiva. 

The  treatment  consists  chiefly  in  frequent  washing  of  the  eye  with  warm  boracic- 
acid  water  in  the  earlier  stages.  Wlien  suppuration  supervenes,  the  indications  are 
the  same  as  for  purulent  ophthalmia. 

Diphtheritic  Conjunctivitis. — In  this  disease,  which  is  exceedingly  contagious, 
the  inflammatory  process  is  rapid  and  often  hopelessly  destructive.  The  lids  soon 
become  greatly  swollen,  and  the  mucous  membranes  are  glazed  over  with  a  tough, 
closely  adherent  diphtheritic  membrane.  The  period  of  iniiltration  varies  from 
six  to  ten  days,  and  is  followed  by  the  stage  of  suppuration. 

Treatment. — The  immediate  danger  is  destruction  of  the  cornea,  the  circulation 
being  more  or  less  interfered  with  by  the  false  membrane.  Since  all  pressure  should 
be  eliminated,  in  extreme  cases  it  will  be  advisable  to  perform  cant] io plasty.  Cold- 
water  dressings  should  be  employed  in  the  early  stages.  Leeches  to  the  temples 
are  advised.    When  suppuration  ensues,  astringents  are  indicated. 

Pterygium  is  the  name  given  to  a  vascular  network  which  extends  from  the 
ocular  conjunctiva  on  to  the  cornea.  It  is  usually  situated  on  the  inner  side,  less 
frequently  on  the  outer  portion  of  the  globe.  It  is  commonly  triangular  in  shape, 
the  apex  encroaching  more  or  less  upon  the  corneal  surface.  It  is  caused  by  con- 
stant irritation  from  dust  or  sand,  or  fine  particles  of  matter  floating  in  the  air, 
and  is  therefore  chiefly  met  with  in  sandy,  arid  regions. 

When  small  and  not  progressive,  it  is  advisable  not  to  interfere  with  pterygium. 
When  it  is  growing  steadily,  it  should  be  tied  off  or  removed  by  dissection.  For  the 
first  method  the  pterygium  is  lifted  at  the  margin  of 
the  cornea,  and  a  fine  silk  thread  carried  beneath  it  here. 
A  second  is  carried  beneath  the  base  of  the  mass  at  the 
conjunctival  fold.  The  ligatures  are  tied  and  cut  short. 
In  a  few  days  they  come  away,  and  the  vascular  tuft 
disappears ;  or  a  dull  instrument,  as  a  strabismus-hook, 
may  be  inserted  beneath  the  pterygium,  which  is  grad- 

FiG.  322  —Pinguecula.  uallv  detached  and  di\  ided  with  the  scissors.     One  or 

(Swanzy.)  two  sutures  are  inserted  to  close  the  wound,  where  the 

base  of  the  growth  is  cut  away  from  the  conjunctiva. 

Pinguecula. — This  is  a  small,  yellow  elevation  occasionally  met  with  at  the  inner 
or  outer  margin  of  the  cornea  (Fig.  322).  It  occurs  usually  in  the  aged,  and  should 
not  be  molested  unless  it  seriously  interferes  with  vision  or  comfort.  It  is  a  simple 
hjrpertrophy  of  the  tissues  of  the  conjunctiva. 

Lupus  of  the  conjunctiva  is  exceedingly  rare,  and  does  not  require  special 
consideration. 

Epithelioma  here  does  not  differ  from  i.his  affection  on  other  mucous  surfaces. 


Fig.  323.— Sichel's  iris  knife. 


Cystic  tumors  occur  in  the  conjunctiva  in  a  certain  proportion  of  cases,  and 
demand  extirpation. 

Polypus  develops  occasionally  on  the  semilunar  fold,  or  caruncula,  and  should 
be  clipped  off. 


THE   EYE  261 

Lithiasis,  or  calcification  of  the  secretion  of  the  Meibomian  glands,  appears  in 
the  shape  of  little  white  spots  or  elevations  on  the  inner  surfaces  of  the  lids.  As 
they  produce  considerable  irritation  of  the  conjunctiva  and  cornea,  they  should 
be  picked  out  -n-ith  a  needle-point  after  anesthesia  with  cocaine  is  secured. 


Fig.  324. — Da\-iels'  curette. 

Xerosis  is  a  temi  applied  to  a  dry  condition  of  the  conjunctiva  resulting  from 
changes  in  the  structure  of  this  membrane  and  deficient  supply  of  the  secretions 
which  moisten  this  surface.  The  indications  are  to  remove,  if  possible,  any  chronic 
inflammatory  condition,  and  keep  the  eye  moist  by  artificial  means. 

COEXEA 

Foreign  Bodies  and  Wounds.- — Xon-penetrating  wounds  of  the  cornea  should  be 
thoroughly  cleansed  with  warm  boracic-acid  solution,  and  the  lids  closed  with  a 
bandage  until  repair  is  effected.  A  penetrating  wound  should  be  treated  on  the 
same  principle  as  the  incision  for  cataract. 

A  foreign  body  lodged  upon  or  buried  in  the  cornea  should  be  at  once  removed. 
Anaesthesia  with  cocaine  is  essential.  Oblique  illumination  by  means  of  the  convex 
lens  is  of  value  in  locating  the  body.  A  clean  needle  or  knife-point  may  be  used  in 
lifting  the  foreign  substance  out. 

Keratitis,  or  comeitis,  may  originate  from  injury  or  disease  of  the  cornea  proper 
or  by  extension  of  the  inflammatoiy  process  from  the  conjunctiva  or  sclerotic,  iris 
or  choroid.  The  symptoms  are  pain  variable  in  character,  interference  with  vision, 
especially  if  the  infiltration  occurs  toward  the  center  of  the  cornea,  and  the  appear- 
ance of  a  cloudy  film  upon  the  normally  clear  and  transparent  membrane. 


^ 


Fig.  325. — Desmarres'  retractors. 


Diffuse  idiopathic  keratitis  usually  commences  at  the  periphery  and  travels 
toward  the  center.  Occurring  as  a  feature  of  a  constitutional  dyscrasia  (s^'philis, 
tuberculosis,  etc.),  both  eyes  are  usually,  though  not  simultaneously,  involved. 

Abscess  of  the  cornea  may  be  recognized  by  the  grayish-yellow  color  of  the  pus 
collection  and  the  greater  density  of  the  membrane  at  this  point.  In  many  eases 
the  transudation  or  escape  of  the  purulent  liquid  takes  place  into  the  anterior  cham- 
ber, and  may  be  seen  to  occupy  the  lower  portion  of  this  space  {hypopyon). 

Treatment. — In  traumatic  l-eratitis  the  removal  of  aU  irritation,  disinfection 
with  warm  boracic-acid  solution,  relief  from  pain  by  cocaine  locally  or  morphia 
internally,  and  the  exclusion  of  light  by  the  dark  room,  bandage,  or  shade,  are  the 
indications. 

Wlien  the  disease  is  secondary  to  inflammation  in  other  parts  of  the  globe  or 
conjunctiva,  the  treatment  should  be  directed  to  the  original  malady  as  well  as  to 
the  protection  of  the  cornea. 

Diffuse  keratitis  demands  active  constitutional  treatment  to  increase  nutrition 
and  neutralize  the  virus  of  general  infection.  In  abscess,  tension  should  be  relieved 
by  careful  pimcture.  Penetration  of  the  anterior  chamber  with  the  instrument 
should  be  avoided,  unless  the  pus  here  is  rapidly  increasing;  it  should  then  be 
evacuated. 

Pannus  is  a  term  applied  to  a  condition  of  opacity  of  the  cornea  due  to  the 
formation  of  a  vascular  network  beneath  the  epithelial  covering  of  this  membrane. 


262 


THE   EYE 


It  is  associated  with  a  conjunctivitis,  the  vessels  really  extending  from  the  con- 
junctiva into  the  cornea. 

If  the  disease  is  due  to  chronic  granular  lids,  entropion,  distichiasis,  etc.,  the 
cause  should  be  at  once  eliminated.  In  milder  cases  of  persistent  pannus  a  cure 
may  be  effected  by  excision  of  a  zone  of  conjunctiva  and  subconjunctival  tissue 
from  aroiind  the  cornea  (Nettleship).  In  severer  cases  the  local  use  of  jequirity- 
bean  is  advised.     Prof.  David  Webster  recommends  the  following: 

One  jequirity-bean  coarsely  powdered  is  placed  in  an  ounce  of  water  for  four 
hours.  The  patient  is  then  required  to  bathe  the  affected  eye  very  freely  with 
this  solution  for  ten  or  fifteen  minutes,  letting  some  of  it  get  into  the  eye.  One 
thorough  washing  will  usually  produce  the  characteristic  membrane  of  the  con- 
junctiva. If  this  does  not  succeed,  the  operation  should  be  repeated.  Or  the  bean, 
very  iinely  pulverized,  may  be  applied  to  the  whole  palpebral  conjunctiva. 
A  convenient  shade  or  screen  for  the  eye  is  shown  in  Pig.  326. 
Ulcus  Gorneee. — Ulcers  of  the  cornea  may  follow  injury,  or  the  eruption  of  her- 
pes or  small-pox;  they  are  met  with  in  conditions  of  general  malnutrition  (syj)hilis, 
tuberculosis,  etc.),  and  may  also  occur  with  inflammation  of  the  other  structures 
of  the  eyeball,  or  of  the  lids  or  conjunctiva. 

Herpetic  vesicles  occur  at  times  upon  the  cornea,  either  as  herpes  zoster  oph- 
thalmicus or  herpes  cornew  fehrilis   (Swanzy).     They  appear  as  groups  of  clear 

vesicles,  the  superficial  covering  of  the  vesi- 
cle giving  way  within  a  few  hours  and  leav- 
ing a  shallow  ulcer.  In  treatment,  herpes, 
or  the  resulting  ulcer,  demands  little  beyond 
protection  from  light,  the  removal  of  all  irri- 
tation by  the  banclage,  and  the  prevention  of 
infection  by  careful  aseptic  irrigation. 


Fig.  327. — Phlyctenula  of  the  conjunctiva  and 
(Travers.) 


Phlyctenule  of  the  Conjunctiva  and  Cornea. — Phlyctenular  ulcers  occur  almost 
invariaWy  in  strumous  subjects,  either  with  or  without  any  direct  exciting  cause. 
When  first  noticed  they  are  usually  papules  or  pustules  on  the  conjunctiva  or  cornea 
or  both.  There  is,  however,  a  localized  hyperasmia  in  and  near  the  spots  where  the 
elevation  occurs  which  precedes  the  papule  or  pustule.  Breaking  down  and  dis- 
charging their  contents,  ulcers  of  variable  extent  are  formed.  They  frequently 
develop  on  the  conjunctiva  and  sclerotic  without  invading  the  cornea.  Not  infre- 
quently, however,  the  process  of  ulceration  travels  on  and  toward  the  center  of  the 
cornea,  leaving  behind  a  trail  of  enlarged  vessels,  giving  to  the  whole  a  comet-like 
appearance  (Fig.  327).  Perforation  may  follow  in  a  certain  proportion  of  cases. 
These  ulcers  may  occur  in  all  ages,  but  are  chiefly  met  with  after  the  third  year 
and  before  the  twenty-fifth  year  of  life. 

Ulcus  Serpens. — The  acute  serpiginous  ulcer  is  probably  due  to  infection.  It 
commences  as  a  grayish  film  or  spot,  breaking  down  from  the  center,  leaving  sharp,, 
precipitous  edges  (as  in  iDhagedenic  chancre),  "one  part  of  which  is  more  densely 
opaque  than  the  rest;  this  infiltrated  advancing  edge  is  the  distinguishing  mark  of 
the  ulcer"  (Nettleship). 

Treatment. — In  phlyctenular  keratitis  and  conjunctivitis  warm  applications  of 
boracic-acid  water  are  useful.     Pain  should  be  relieved  as  heretofore  directed.     If 


THE   EYE  263 

blepharospasm  is  present,  canthotomy  may  be  necessary.  The  ulcers  should  be 
stimulated  locally  by  use  of  nitrate  of  silver  to  those  on  the  conjunctiva,  the  miti- 
gated stick ;  while  weaker  solutions  (gr.  v-x,  gj )  may  be  used  for  the  corneal  ulcers. 
In  given  cases  the  ulcers  may  be  scraped  out  or  burned  with  the  line  galvano-cautery 
platinum  wire.  The  prevailing  dyscrasia  should  be  corrected  by  appropriate  reme- 
dies.   The  nutrition  should  be  increased,  and  an  out-of-door  life  advised. 

In  acute  serpiginous  ulcer  active  measures  are  often  imperative,  the  phage- 
denic process  marching  rapidly  to  perforation  and  collapse  of  the  globe.  Hot 
boracic-acid  water  applications  at  intervals  of  an  hour  or  two  are  advised  for  relief 
of  pain.  Cocaine  maj'  also  be  instilled.  If  the  ulcer  does  not  remain  stationary, 
it  should  be  carefully  and  thoroughly  burned  with  the  cautery  needle  upon  the 
same  principle  as  for  chancroidal  ulcer  of  the  skin.  When  the  serpiginous  ulcer 
dips  down  into  the  deeper  corneal  tissue  and  undermines  it,  it  should  be  laid  open 
by  incision  in  its  entire  extent. 

Staphyloma  Cornece. — Bulging  of  a  portion  of  the  corneal  surface  may  result 
from  intra-ocular  tension  upon  a  point  weakened  by  ulceration  or  cicatrization. 
Conical  cornea  diifers  from  this  in  Ijeing  due  to  atrophic  (not  inflammatory) 
changes  in  the  central  portion  of  the  cornea,  this  part  projecting  by  reason  of 
intra-ocular  tension.  When  perforation  takes  place,  the  aqueous  humor  escapes 
and  usually  carries  the  iris  with  it,  this  latter  structure  being  caught  in  the  open- 
ing, where  it  adheres.    This  condition  is  known  as  anterior  synechia. 

When  the  staphyloma  involves  a  limited  portion  of  the  cornea,  iridectomy  should 
be  done,  making  the  artificial  jjupil  behind  the  best  remaining  surface  of  the  cor- 
nea. In  comjDlete  staphyloma,  vision  being  lost,  Critchett's  operation  is  advisable. 
Pive  half-curved  needles,  threaded  with  fine  strong  silk,  are  passed  from  above 
downward  through  the  sclerotic,  being  made  to  enter  and  exit  half-way  between 
the  insertions  of  the  recti  muscles  and  the  posterior  edge  of  the  staphyloma.  When 
the  point  of  each  needle  has  emerged  about  one  quarter  inch,  it  is  allowed  to 
remain,  and  the  staphyloma  is  divided  by  a  horizontal  incision.  The  flaps  are 
now  snipped  off  with  the  scissors  about  one  twelfth  inch  in  front  of  the  needles, 
this  line  (see  the  dotted  line.  Fig.  328)  being  through  the  sound  sclerotic.  The 
needles  are  next  drawTi  through  and  the  sutures  tied,  as  in  Fig.  329. 


Pig.  32S  — Needles  introduced  in  Critchett's  Fig.  329. — The  same,  after  the  sutures  are  tied, 

operation  for  staphyloma.     (Abadie.)  (Swanzy.) 

In  conical  cornea,  if  any  operative  interference  is  deemed  advisable,  the  conicity 
should  be  reduced  by  inducing  cicatrization  at  and  about  the  apex  of  the  projection. 

Von  Graefe's  Method. — Just  to  one  side  of  the  apex  of  the  cone  remove  with 
the  knife  a  small  bit  of  the  surface  of  the  cornea  without  penetrating  the  anterior 
•chamber.  Every  third  day  for  about  two  weeks  this  wound  should  be  touched  with 
the  mitigated  pencil  of  nitrate  of  silver.  Then  puncture  through  this  scar  every 
second  or  third  day  for  one  week,  evacuating  at  each  puncture  the  aqueous  humor. 
The  wound  is  now  allowed  to  heal. 

Nebula,  macula,  and  leucoma,  are  terms  used  to  designate  degrees  of  corneal 
opacitj' — the  first  being  so  slight  as  to  be  scarcely  discernible,  the  second  a  more 
serious  lesion,  while  in  leucoma  the  opacity  is  complete.  The  grayish  ring  seen 
at  the  corneal  margin  in  many  old  persons — arcus  senilis — is  due  to  fatty  degenera- 


264  THE   EYE 

tion  of  the  cells  of  the  cornea,  near  the  sclerotic  Junction.  This  condition  occa- 
sionally exists  in  the  middle-aged  and  in  young  children.  Wliile  not  a  contra-indi- 
cation  to  operative  interference,  that  it  suggests  faulty  nutrition  should  not  be 
forgotten  in  prognosis. 

Sclerotic 

Simple  incised  wounds  of  the  sclerotic  heal  readily.  Lacerations  are  more  seri- 
ous by  reason  of  the  greater  violence  accompanying  such  injuries.  No  special  treat- 
ment is  demanded  beyond  rest  and  cleanliness. 

Scleritis. — Inflammation  of  the  sclera  is  usually  circumscribed,  and  may  or 
not  be  accompanied  by  an  appreciable  thickening  of  this  tunic.  As  a  rule,  the 
affection  is  not  piainful,  unless  it  extends  so  widely  that  the  choroid,  cornea,  or 
iris  is  involved. 

Treatment  should  be  directed  to  the  prevailing  dyscrasia.  It  is  met  with  as  a 
late  manifestation  of  syphilis,  and  is  also  a  symptom  of  rheumatism.  ISTo  local 
medication  is  advisable,  beyond  the  limited  instillation  of  atropine  to  prevent  iritis. 
Eest,  and  light  cloths  wet  in  warm  boracic-aeid  solution  locally,  are  advised.  A 
single  thorough  application  of  the  actual  cautery  will  frequently  abort  this  disease, 
which  under  other  methods  of  treatment  usually  lasts  many  months. 

Iris 

Iritis  is  most  frequently  seen  as  a  late  manifestation  of  syphilis  or  in  chronic 
rheumatism.  It  also  may  occur  with  inflammation  of  the  cornea  or  sclera.  The 
symptoms  are  abnormal  immobility,  thickening  and  cloudiness  of  the  organ,  irregu- 
larity of  the  pupillary  margin,  and  adhesions  to  the  anterior  surface  of  the  capsule 
of  the  lens  (posterior  synechia).  The  injected  zone  is  usually  of  a  pinkish  color. 
Vision  is  more  or  less  affected;  and  pain,  though  not  always  a  symptom,  is  usually 
present.  In  rare  cases  the  pupil  is  occluded  by  the  formation  of  a  memlDrane  from 
the  products  of  inflammation. 

The  treatment  of  iritis  is  local  and  general.  To  prevent  permanent  adhesions 
and  to  relieve  pain,  the  instillation  of  atropine  solution — gr.  iv  to  water  §j — is 
imperative.  From  one  to  two  minims  should  be  dropped  in  the  conjunctival  sac 
every  hour,  in  the  first  few  days  of  the  attack.  The  degree  of  synechia  is  evident 
as  soon  as  the  iris  is  affected  by  the  atrojDine,  and  even  when  the  adhesions  between 
the  capsule  of  the  lens  and  the  iris  are  not  completely  relieved,  firmer  and  more 
injurious  adhesions  will  be  prevented.  Bloodletting  at  the  temples,  either  by  scari- 
fication and  cups,  or  dry  cupping,  hot  fomentations,  etc.,  are  local  remedies  of 
value.  Eest  to  the  eyes  should  be  complete,  and  exposure  to  draughts  or  extreme 
changes  in  temperature  are  to  be  avoided.  Any  constitutional  disease  should  be 
treated  or  any  diathesis  corrected  by  internal  medication.  Saline  laxatives  are 
indicated,  as  in  other  inflammatory  affections. 

In  extreme  cases,  when  all  other  remedial  agents  fail,  iridectomy  may  be  necessi- 
tated. This  operation  will  be  described  hereafter.  The  permanent  changes  to 
which  the  iris  is  subject,  after  iritis,  are  adhesions  (synechice),  atrophy  of  the 
curtain  at  one  or  many  points  as  the  effusion  disappears,  and  changes  in  color  due 
to  absorption  of  the  normal  pigment. 

Choroid  and  Ciliary  Body 

Choroiditis  is  occasionally  of  traumatic  origin.  The  lines  of  rupture  are  seen 
most  frequently  hear  the  optic  disk,  and  in  recent  injuries  may  be  concealed  by 
extravasation.  Idiopathic  choroiditis  occurs  often  in  the  tertiary  step  of  syphilis. 
A  less  frequent  variety  is  of  tuberculous  origin. 

The  diagnosis  rests  chiefly  upon  examinations  with  the  ophthalmoscope.  Dis- 
ease is  evident  from  the  abnormal  paleness  due  to  atrophy  and  diminution  of  the 
blood-supply.  It  may  be  general  and  sjaumetrieal  in  the  two  eyes  (syphilis),  or 
confined  to  one  or  more  isolated  patches  {tuberculosis).     In  the  syphilitic  variety. 


THE   EYE  265 

changes  in  the  retina  are  more  evident.  In  very  old  persons  an  extensive  area  of 
atrophy  may  occasionally  be  observed,  situated,  as  a  rule,  at  the  fundus. 

The  indications  in  treatment  are  to  correct  the  prevailing  dyscrasia,  by  specific 
remedies  and  tonics,  and  to  give  the  eye  as  complete  rest  as  possible. 

Cyditis  occurs  rarely  except  as  in  conjunction  with  inflammation  of  the  scle- 
rotic choroid  or  iris. 

Sympathetic  ophthalmitis  is  a  term  applied  to  inflammation  in  one  eye,  fol- 
lowed by  a  like  disturbance  in  and  threatened  destruction  of  the  other.  It  is  very 
apt  to  occur,  after  traumatic  cyditis,  from  a  penetrating  body.  Dislocation  of  the 
lens,  iritis,  or  any  inflammatory  process,  without  penetration,  and  the  entrance  of 
air  or  a  foreign  substance,  may  also  cause  this  form  of  ophthalmitis. 

The  invasion  from  one  eye  to  the  other  is  now  believed  to  be  by  means  of  septic 
bacteria  traveling  along  the  optic  nerve  and  chiasm.  When  once  declared,  the 
remedy  of  most  avail  is  enucleation  of  the  diseased  eye.  It  is  important  that  this 
operation  be  not  too  long  postponed.  The  chief  difBculty  to  be  surmounted  is  to 
determine  when  it  is  necessary  to  operate.  The  following  rules  may  serve  as  a 
guide: 

When  a  penetrating  se2:)tic  body  has  entered  the  eye  and  destroyed  vision,  it 
would  be  wise  to  enucleate  even  before  iritis  and  cyclitis  are  established,  and  if 
these  symptoms  of  ophtlialmitis  are  f)resent,  operation  is  imperative.  Enucleation 
is  indicated  in  an  eye  in  which  a  foreign  body  is  lodged  with  vision  not  materially 
impaired  when  the  earliest  sjinptoms  of  irido-cyclitis  suj^ervene. 

Idiopathic  inflammation  of  the  interior  of  the  globe,  which  destroys  vision,  also 
indicates  enucleation. 

Operation. — Seize  the  conjunctiva  with  a  mouse-tooth  forceps  near  the  margin 
of  the  cornea,  and  with  delicate  scissors  divide  the  conjunctiva  evenly  all  the  way 


Fig.  330. — Jaeger's  angular  keratome. 

around  close  to  the  cornea.     Introduce  the  strabismus-hook  and  divide  the  internal 
muscle  at  its  insertion  into  the  globe.    The  other  recti  muscles  are  then  successively 


Fig.  331. — Beers'  keratome. 

divided.  The  ball  is  then  carried  toward  the  nose  and  a  dull-pointed  scissors  curved 
on  the  flat  is  carried  (concavity  to  the  globe)  backward  and  the  nerve  divided  close 
to  the  ball.    The  attachments  of  the  oblique  muscles  are  next  cut  through. 


Fig.  332. — Iris  forceps. 

An  artificial  eye  should  not  be  worn  until  the  stump  is  healed,  which  requires 
about  five  weeks. 

Glaucoma. — This  disease  is  almost  always  met  with  after  the  fortieth  year,  and 
is  more  common  in  the  hypermetropic  than  in  the  myopic  eye. 

The  prevailing  symptom  is  an  increased  tension  of  the  eyeball. 

Glaucoma  may  be  acute,  subacute,  or  chronic.  In  rare  instances,  it  occurs  with 
great  rapidity  (g.  fulminans).  More  frequently  it  is  slower  in  its  progress.  The 
earliest  symptom  is  dimness  of  vision.  Patients  usually  complain  of  indistinct- 
ness of  sight,  as  if  .they  were  looking  through  frosted  glass.     These  attacks  are  at 


266 


THE   EYE 


first  commoiily  periodic,  but  the  interference  with  vision  soon  becomes  permanent. 
Halos  or  rainbows  are  seen  when  an  artificial  light  is  looked  at.  The  cornea  has  a 
dead  and  glazed  appearance,  the  pupil  is  dilated,  the  anterior  chamber  shallow,  and 


the  iris  is  not  so  movable  as  normal.  If  the  pulp  of  the  finger  is  pressed  upon  the 
eyeball,  it  is  felt  to  be  hard  and  abnormally  inelastic.  Pain  is  not  always  present. 
Inflammation  may  or  may  not  occur.     Blindness  sooner  or  later  supervenes,  unless 


Fig.  334. — Drum  for  trying  the  edge  of  eye  instruments. 

jjrevented  by  treatment.  The  causes  of  glaucoma  are,  as  yet,  not  satisfactorily 
explained.  It  is  more  generally  held  that  obstruction  of  the  efferent  lymph-chan- 
nels, or  of  the  vessels  which  carry  off  the  intravascular  fluids,  is  the  chief  cause 
of  this  disease. 

Treatment. — The  chief  reliance  is  in  iridectomy.     With  the  iridectomy  knife, 
enter  the  anterior  chamber  by  cutting  through  the  sclerotic  near  the  corneal  border, 
exposing  the  upper  margin  of  the  iris  for  at  least  one  fifth  of 
its  circumference.    Divide  the  iris  at  one  end  of  the  incision  in 
a  line  radiating  from  its  pupillary  margin  to  its  ciliary  attach- 
ment, Ijy  traction  tear  it  from  the  ciliary  attachment  and  di- 
vide with  the  scissors  at  the  other  limit,  severing  one  fifth  of 
the  membrane  (Fig.  335).     N'o  particle  of  iris  should  be  al- 
lowed to  be  caught  and  remain  in  the  wound.     The  after- 
treatment  consists  in  bandaging  the  eye,  and  complete  rest. 
In  mild  cases,  a  smaller  section  of  the  iris  should  he  made.     The  edge  may  be 
drawn  out  with  the  forceps  and  a  loop  of  iris  clipped  off  with  the  scissors. 


Fig.  335. — Iridectomy 
for  glaucoma.  (De 
Wecker.) 


Crystalline  Lens 

Cataract,  or  opacity  of  the  lens,  although  chiefly  encountered  after  the  fortieth 
year  of  age,  may  occur  at  any  period  of  life.  It  may  be  divided  into — 1,  congenital 
or  infantile  cataract;  2,  cataract  of  adult  and  middle  life  (before  forty)  ;  3,  senile 
cataract. 

Cataracts  are  also  classified  according  to  their  location  in  the  lens — nuclear, 
or  central;  cortical,  or  peripheral;  and  capsular. 

Nuclear  cataract  occupies  the  center  of  the  lens,  either  permanently,  or  spreads 
gradually  until  the  organ  is  entirely  involved.  It  is  at  first  observed  as  an  opacity 
or  cloudiness  immediately  behind  the  ]5upil,  white  or  amber-brown  in  color. 

Cortical  cataract  commences  near  the  margin  of  the  lens,  Ijehind  the  iris,  and 
is  characterized  by  grayish-white  lines  or  streaks  projected  toward  the  center  of 
the  pupil. 


THE   EYE  267 

In  the  capsular  variety-  the  cloudiness  or  opaeit\-  is  confined  to  the  anterior  shell 
of  the  capsule,  the  substance  of  the  lens  not  being  affected. 

Cataracts  -svhich  are  congenital,  or  only  observed  ia  early  infancy,  are  classified 
as  anterior  polar,  or  pyramidal;  lamellar,  or  zonular;  central,  posterior  polar,  and 
fusiform.    All  of  these  types  are  comparatively  rare. 

The  anterior  polar  variety  is  due  to  the  formation  of  a  chalky  concretion  in  the 
center  of  the  anterior  lamellfe  of  the  lens,  caused  by  inflammation  and  perforat- 
ing ulcer  of  the  cornea  ia  the  early  days  of  life.  Operative  interference  is  not 
called  for. 

In  lamellar  or  zonular  cataract  the  opacity  is  limited  to  a  thin  layer  of  lens- 
substance,  about  half-Tvay  between  the  nucleus  and  the  anterior  and  posterior  sur- 
faces. The  nucleus  and  peripheral  portions  are  normal.  When  vision  is  seriously 
interfered  with  by  this  form  of  opacit}",  it  may  be  improved  by  iridectomy  or  iaci- 
sion  through  the  anterior  layer  of  the  capsule  (discission).  In  some  cases  extrac- 
tion is  advisable. 

In  central  cataract  the  deeper  fibers  of  the  lens  only  become  opaque.  It  may 
be  treated  ia  the  same  way  as  the  zonular  opacity.  Posterior  polar  cataract  is  seen 
deeply  behind  the  center  of  the  lens.  Operative  treatment  is  rarely  demanded,  and 
when  radicated  discission  is  advised. 

Fusiform  opacitv"  extends  from  the  posterior  to  the  anterior  pole.  It  is  very 
rare. 

Cataracts  are  primary  when  the  opacitv'  is  developed  independent  of  any  other 
lesion  of  the  eye,  and  secondary  when  some  other  lesion  exists.  A  traumatic  cata- 
ract occurs  as  a  result  of  rupture  of  the  capsule,  with  or  without  perforation,  aUow- 
iag  the  aqueous  humor  to  invade  the  crystalline  substance.  A  Morgagnian  cataract 
is  one  in  which  partial  liquefaction  of  the  cortex  has  taken  place,  and  the  nucleus 
drops  to  the  lowest  portion  of  the  capsule.  The  opacity  occiu-ring  ia  diabetes  mel- 
litus  is  eaUed  diabetic  cataract. 

Cataracts  are  also  termed  senile,  hard,  and  soft.  Senile  cataract  occurs,  as  its 
name  implies,  in  old  persons,  usually  very  late  ia  life,  but  not  unfrequently  as 
yotmg  as  the  fortieth  year.  This  variety,  though  usually  firm  or  hard,  is  at  times 
soft.  Under  forty  years  cataracts  are  usually  soft.  A  cataract  is  said  to  be 
"  ripe  '*'"  when  the  entire  lens  has  become  opaque. 

Symptoms  and  Diagnosis. — ^With  senile  cataract  the  earlier  symjjtoms  are  dis- 
turbance of  vision.  Indistinctness  of  vision  for  distant  objects  is  usually  first 
noticed,  and,  ia  certaia  eases,  multiple  images  of  one  object  are  observed.  If  the 
cataract  is  nuclear  or  central,  vision  is  improved  by  shading  the  eye,  thus  allowing 
the  pupil  to  dUate.  In  cortical  cataract  this  is  not  the  case,  but  by  dilatation  of 
the  pupil  with  atropine  the  presence  of  the  peripheral  opacity  may  be  detected, 
■^lien  a  cataract  is  general  and  ripe,  blindness  for  objects  is  complete,  althoitgh  light 
and  darkness  are  appreciable. 

Examiaed  ia  ordinary  light  a  well-marked  nuclear  cataract  may  be  recog- 
nized: but  it  is  by  focal  illumiaation  and  by  the  ophthalmoscope  that  a  diagnosis 
is  positively  made.    The  pupd.  shoidd  be  dilated. 

A  large  nucleus  with  very  fine  radiatiag  strife  indicates  a  hard  cataract,  while 
a  small  nucleus  and  large  striae  suggest  a  soft  opacity.  If  the  cataract  be  ripe, 
no  clear  space  will  be  discovered  between  the  nucleus  and  the  iris,  and  no  shadow 
will  be  thrown  upon  the  nucleus  by  the  iris.  Focal  (oblique)  illumination — ^i.  e., 
concentratiag  by  means  of  a  prism  the  rays  of  a  strong  light  let  fall  obliquely 
upon  the  cornea — is  essential  ia  this  examination.  By  the  ophthalmoscope  the 
normal  red  reflex  from  the  fundus  is  absent   (Swanz;^-). 

As  it  is  important  to  have  a  cataract  ripe  when  an  operation  is  undertaken, 
Foster  submits  the  following  general  guide:  Cataracts  which  are  ripe,  according 
to  the  tests  just  given,  and  in  which  there  are  no  sectors  shining  lil-e  mother-of- 
pearl,  are  considered  ripe  for  operation.  In  color  they  are  wliite,  yellow,  or  gray: 
also  when  the  lens  is  wholly  occupied  with  a  browaish-yeUow  nucletis.  This  may  be 
semi-transparent,  and  the  iris  throw  a  distinct  shadow. 

Treatment. — Wlien  a  cataract  is  not  ready  for  operation,  the  vision  may  be 
improved  by  glasses,  which  shade  the  eyes,  allowing  the  pupU  to  dilate,  and  by  the 


268 


THE   EYE 


instillation  of  weak  atropine  solution.  These  measures  apply  to  opacities  at  or 
near  the  antero-posterior  axis  of  the  lens. 

Opacities  of  the  lens  may  be  removed  by  three  methods:  Solid  extraction,  ab- 
sorption after  discission,  and  suction.  The  first  method  is  applicable  to  all  forms 
of  ripe  cataract;  the  lamellar,  central,  posterior  polar,  and  fusiform  varieties  are 
treated  by  discission  when  any  operative  interference  is  indicated;  soft  opacities 
are  removable  by  suction. 

Extraction  is  not  imperative  when  only  one  lens  is  affected,  vision  being  about 
perfect  in  the  other,  unless  the  cataract  is  becoming  overripe.  It  is  advisable  to 
remove  only  one  lens  at  a  single  operation,  even  in  double  ripe  cataract. 

Operation  is  not  advisable  when  any  serious  intra-ocular  complication  exists,  or 
when  insurmountable  opacity  of  the  cornea  is  present.  It  is  always  advisable  to 
allay  any  existing  inflammation  of  the  ball  or  appendages  before  an  operation  for 
cataract.  When  a  cataract  is  not  ripe,  its  solidification  may  be  hastened  by  mas- 
sage of  the  globe — that  is,  by  pressure  applied  over  the  ball  with  the  tips  of  the 
fingers.  The  massage  should  last  a  few  minutes,  and  be  repeated  every  few  days 
as  indicated. 

Operation  of  Extraction. — Two  principal  methods  of  extraction  are  at  present 
employed,  viz.,   (1)   simple  extraction  and   (2)    extraction  after  iridectomy.     The 


Fig.  336. — Graefe's  speculum. 

former  is  the  ideal  operation,  and,  although  at  this  date  not  so  generally  employed, 
is  fast  gaining  in  popularity. 

Simple  Extraction. — The  most  careful  asepsis  is  demanded.  The  eye  should 
be  irrigated  with  warm  boracic-acid  solution  (gr.  x-xv  to  §J).  The  instruments 
should  be  thoroughly  cleansed  by  boiling  and  immersion  in  alcohol.  Anspsthesia 
is  obtained  by  dropping  several  minims  of  two-per-cent  cocaine  hydrochlorate  into 


Fig.  337. — Graefe's  fixation-forceps. 

the  eye,  five  minutes,  and  again  three  minutes,  before  the  operation.  The  head 
should  be  so  held  that  the  cocaine  rests  in  contact  with  the  upper  surface  of  the 
cornea  through  which  the  incision  is  made.  When  ready  to  operate,  the  eye  and 
conjunctival  sac  should  be  dried  with  absorbent  boracic-acid  cotton  pellets.  The 
speculum  is  introdiiced  and  secured,  and  the  conjunctiva  seized  with  fixation- 
forceps  just  below  the  center  of  the  lower  margin  of  the  cornea.    The  ball  is  drawn 


Fig.  33S. — Graefe's  linear  knife. 

slightly  downward  and  steadied,  while  the  knife,  cutting  edge  upward,  is  entered 
through  the  cornea  just  at  the  corneo-sclerotic  junction,  carried  carefully  across 
in  front  of  the  iris,  which  must  not  be  touched,  and  out  at  a  point  corresponding 
to  that  of  entrance  (Fig.  339).  By  careful  to-and-fro  movements,  the  flap  is  made 
by  cutting  upward  through  the  cornea  just  anterior  to  the  sclerotic  junction.  The 
line  between  the  angles  of  this  flap  should  cross  the  cornea  a  little  more  than  one 
third  the  distance  from  the  upper  to  the  lower  margin.     As  this  section  is  being 


THE  EYE 


269 


made,  and  before  the  aqueous  humor  escapes,  an  assistant  should  slightly  lift  the 
speculum,  so  that  no  pressure  may  be  made  by  it  upon  the  ball. 

The  cystotome  is  now  carried  through  the  wound,  kept  clear  of  the  iris  by  the 
operator,  who  very  cautiously  scratches  through  the  anterior  capsule,  through  the 
whole  width  of  the  pupil.  Care  must  be  taken  not  to  press  so  hard  against  the  lens 
as  to  dislocate  it.  As  soon  as  the  eapsiile  is  opened,  gentle  pressure  in  an  upward 
direction  should  be  exercised  by  means  of 
the  spoon  against  the  lower  margin  of  the 
cornea,  or  pressure  with  the  finger  on  the 
lower  lid  may  suffice  to  deliver  the  Jens 
through  the  pupil  and  out  through  the 
wound  of  incision.  The  pressure  should 
be  carefully  gauged  to  effect  only  the  exit 
of  the  cataract,  and  not  to  rupture  the 
zonula.  The  wound  should  now  be  exam- 
ined, and  no  particle  of  iris,  lens,  or  cap- 
sule should  be  left  in  the  incision.  A 
drop  of  eserine  solution  (gr.  ij-oj)  is  now 
instilled  into  the  conjunctival  sac  in  order 
to  contract  the  pupil.  The  eye  is  finally 
irrigated  with  the  boracic-acid  solution  and 
the  dressing  applied,  and  both  eyes  closed 
by  bandaging.  The  patient  is  required  to 
remain  quiet  in  a  light  room  for  a  week. 

made  on  the  second  day,  and  daily  thereafter.  Strict  asepsis  is  essential  at  each 
change  of  dressing.  The  light  should  be  excluded  only  from  the  eyes  by  bandages 
and  shades,  and  not  from  the  room.  At  the  end  of  a  week  or  ten  days  a  black 
silk  shade  may  be  substituted  for  the  bandages,  and  in  from  two  to  three  weeks  the 


Fig.  339. — Introduction  of  Graefe's  knife 
showing  size  of  corneal  flap  in  extraction  of 
cataract.      (Swanzy.) 

The  first  change  of  dressing  should  be 


Fig.  340. — Cystotome  and  Daviels'  spoon. 


patient  will  need  only  medium  smoke  coquilles  to  protect  his  eyes  from  the  strong 
light.  He  should  not  be  fitted  with  cataract  glasses  until  aU  signs  of  redness  and 
sensitiveness  have  disappeared. 

Extraction  with  Iridectomy. — The  speculum  is  introduced  and  secured,  and  the 
ball  steadied  by  grasping  a  fold  of  the  conjunctiva.  Just  below  the  center  of  the 
lower  margin  of  the  cornea  (Fig.  339),  with  a  mouse-tooth  fixation-forceps.  The 
ball  is  drawn  slightly  do^\'iiward,  and  the  Von  Graefe  Icnife,  edge  upward,  is  made 
to  enter  the  cornea.  Just  at  the  sclerotic  Junction,  at.  a  point  three  millimeters 
(about  one  eighth  of  an  inch)  below  the  highest  margin  of  the  cornea  (or  about 
one  third  of  the  distance  between  the  upper  and  lower  margins  of  the  cornea). 
The  point  is  then  made  to  emerge  accurately  opposite  the  entrance,  when,  by  a 
gentle  movement  of  the  knife,  the  flap  is  completed  by  cutting  through  the  cornea, 
Just  anterior  to  its  Junction  with  the  sclerotic.  As  this  flap  is  made,  a  certain 
proportion  of  the  aqueous  humor  escapes.  The  fixation-forceps  being,  at  this  stage, 
transferred  to  an  assistant,  the  iris-forceps  are  introduced,  and  the  iris  seized 
at  a  point  corresponding  to  the  center  of  the  incision,  and  carefully  drawn  out 
through  the  woimd.  A  narrow  strip,  including  the  entire  depth  of  the  iris,  is 
then  excised. 

As  soon  as  the  iridectomy  is  completed  the  operator  relieves  the  assistant  of 
the  fixation-forceps,  directs  that  the  speculum  be  lifted,  so  that  no  pressure  is  made 
on  the  e3'eball,  while,  with  the  cystotome  carried  into  the  anterior  chamber,  he 
freely  scratches  through  the  anterior  layer  of  the  capsule.  Care  must  be  taken 
not  to  press  so  hard  against  the  lens  as  to  dislocate  it.  It  is  also  important  to 
see  that  no  shred  of  the  capsule  is  dragged  out  into  the  wound  in  withdrawing  this 
instrument.     The  globe  should  now  be  depressed,  either  with  the  forceps  or  by 


270  THE   EYE 

the  patient's  volition,  and  the  cataract  extracted  by  gentle  pressure  with  the  spoon 
from  the  lower  margin  of  the  cornea  upward.  The  pressure  should  be  carefully 
gauged,  and  the  wound  examined  as  above  described.  Should  bleeding  occur,  this 
may  be'  checked  by  a  light  compress  of  cold  boracic  solution.  The  after-treatment 
is  the  same  as  just  given. 

If  the  primary  incision  should  not  be  large  enough  to  allow  the  easy  escape 
of  the  lens,  it  should  be  enlarged,  preferably  with  the  iris-scissors;  it  should  be 
free,  to  begin  with.  If  any  fragments  of  the  lens  adhere  to  the  capsule  or  are 
caught  in  the  wound,  they  must  be  worked  out  by  careful  manipulation.  Should 
the  zonula  be  ruptured,  allowing  the  vitreous  to  escape,  the  lens  should  be  ex- 
tracted with  the  scoop.  The  vitreous  should  be  divided  with  the  scissors  at  the 
level  of  the  wound. 

Should  septic  infection  occur,  suppuration  of  the  wound  follows,  with  usually 
destruction  of  the  eye.  The  treatment  should  be  frequent  irrigation  with  boracic- 
acid  solution,  and  the  galvano-cautery  wire  applied  to  the  margins  of  the  wound. 
When  iritis  is  precipitated,  atropine  should  be  instilled  and  warm  boracic-acid 
water  dressings  applied.  -^ 

Strong  convex  glasses  are  necessary  after  the  operation,  but  the  eyes  should 
not  be  used  for  reading,  etc.,  for  three  or  four  months.  Two  pairs  of  glasses  should 
be  prescribed — one  for  reading  and  another  for  vision. 


Fig.  341, — Beers'  straiglit  needle. 

Discission. — After  dilatation  with  atropine,  and  with  ether  narcosis  to  prevent 
any  movement  which  might  displace  the  lens,  the  speculum  is  introduced,  and  the 
field  of  operation  rendered  aseptic. 

The  point  of  the  cataract-needle  is  made  to  pass  through  the  cornea  near  the 
outer  margin,  and  the  point  carried  to  the  center  of  the  pupil,  where  it  enters 
the  capsule  of  the  lens  (Fig.  342).    The  capsule  and  the  anterior  superficial  layers 

of  the  lens  are  torn  open  by  gentle  movements 
of  the  point  of  the  instrument,  which  is  then 
withdrawn,  being  careful  not  to  injure  the  iris. 
The  pupil  should  be  kept  fully  dilated,  renewing 
the  instillation  every  few  hours,  if  necessary,  for 
several  days.  Cold  applications  and  a  dark  room 
are  the  chief  indications  in  the  after-treatment. 
If  successful,  the  lens  becomes  opaque  after  a 
week  or  more,  and  gradually  disappears  by  ab- 
sorption.    A  second  operation  may  be  necessary. 

Suction. — Dilate    with    atropine,    administer 
ether,  incise  the  cornea  half-way  between  its  cen- 
FiG.  342.— Introduction  of  the  needle    tcr   and   margin,   perform   discission,   and   intro- 
in  discission.    (Swanzy.)  duce  the  nozzle  of  the  Syringe  into  the  lens,  when 

it  and  the  capsule  are  broken  up.  The  softened 
lens  is  sucked  into  the  cylinder  by  steady  and  gradual  traction  on  the  piston.  Strict 
asepsis  is  essential.  A  single  introduction  of  the  instrument  is  advisable.  The 
after-treatment  is  the  same  as  for  discission. 

The  Vitkeous 

Hyalitis,  or  inflammation  of  the  vitreous,  may  result  from  traumatism,  with  or 
without  the  presence  of  a  foreign  body,  or  by  the  extension  of  some  idiopathic  in- 
flammatory process  from  the  choroid,  iris,  or  any  portion  of  the  globe.  Syphilitic 
choroiditis  is  especially  apt  to  produce  hyalitis.  The  immediate  S3'mptom  is  opacity 
due  to  extravasation  of  blood,  or  the  exudation  of  the  products  of  inflammation. 
The  vitreoiis  breaks  down,  becoming  more  fluid  than  normal   (synchisis).     Flakes 


THE   EYE  271 

or  small  collections  of  more  solid  matter  may  be  seen  to  change  position  as  tlie 
position  of  the  globe  is  changed.  "  Spots  before  the  eyes "  {muscm  volitantes) 
occur  chiefly  in  myopic  subjects,  and  are  due  to  changes  in  the  vitreous. 

The  exact  condition  of  the  vitreous  can  usually  be  made  out  by  careful  exami- 
nation with  the  ophthalmoscope. 

Poreign  bodies,  when  composed  of  small  bits  of  metal,  may  be  removed  by  the 
electro-magnet.  Should  the  wound  in  the  sclerotic  be  not  sufficient,  it  should  be 
enlarged  and  the  middle  of  the  magnet  carried  into  the  vitreous.  The  metal,  if 
not  impacted,  adheres  to  the  magnet  and  is  withdrawn.  When  the  foreign  body 
is  non-metallic,  operative  interference  is  of  doubtful  propriety  unless  general  in- 
flammation is  taking  place.  Idiopathic  hyalitis  should  be  treated  by  rest  to  the 
eye  and  by  special  medication. 

The  Eetina 

Inflammation  of  the  retina  {retinitis)  may  occur  independently  of  lesion  of 
any  other  portion  of  the  eye,  or  it  may  be  part  of  air  inflammation  of  the  choroid, 
ciliary  body,  iris,  vitreous,  or  by  extension  from  the  optic  nerve.  It  is  not  uncom- 
mon in  syphilis,  and  follows  thrombosis  and  embolism  of  the  vessels.  It  is  met 
with  in  nephritis,  in  diabetes,  and  in  severe  cerebral  hyperfemia. 

Detachment  of  the  retina  from  the  choroid  may  be  due  to  extravasation  of  blood 
or  transudation  of  serum. 

All  these  conditions  may  be  determined  by  a  careful  analysis  of  the  symjitoms 
present  and  by  ophthalmoscopic  examination.  The  indications  in  treatment  are 
chiefly  to  correct  the  general  condition  of  disease  on  which  the  retinitis  depends. 
When  of  traimiatic  origin,  the  chief  reliance  is  upon  complete  rest  and  warm  fomen- 
tations. In  certain  morbid  conditions  of  the  external  portions  of  the  retina,  objects 
appear  unusually  small  (micropsia).  The  opposite  of  this  condition  is  known  as 
megalopsia. 

jSTight-blindness  (liemeralopia)  is  usually  only  a  symptom  of  retinitis  pigmen- 
tosa, but  sometimes  occurs  in  other  diseases  of  the  retina  and  optic  nerve. 

Day-blindness  (ni/ctalopia)  is  generally  due  to  exposure  to  strong  light,  as 
the  glare  of  the  ocean  in  the  tropics,  and  may  occur  in  persons  of  faulty 
nutrition. 

Optic  Neuritis. — The  optic  nerve  is  at  times  the  seat  of  neuritis  which  may 
originate  here,  or  descend  from  the  brain  along  the  nerve;  it  may  be  secondary 
to  retinitis,  or  become  involved  by  contact  with  morbid  changes  occurring  in  the 
lymph  spaces  and  other  tissues  contiguous  to  it.  The  subjective  symptoms  are  vary- 
ing degrees  of  interference  with  vision.  Amblyopia  (dimness  of  sight),  or  amau- 
rosis (complete  blindness),  may  be  present.  These  symptoms  may  be  present 
without  perceptible  change  in  the  appearance  of  the  retina  or  optic  papilla.  When 
the  lesion  is  beyond  the  disk,  atrophic  or  other  changes  of  the  papilla  may  be 
recognized  by  the  ophthalmoscope. 

In  some  instances  the  obliteration  of  the  retinal  image  is  confined  to  a  portion 
of  the  field  of  vision,  usually  one  half  (hemianopsia) .  If  one  eye  only  is  involved, 
the  lesion  is  peripheral  and  limited  to  the  nerve  or  retina  of  the  affected  eye.  If 
binocular,  the  lesion  is  in  or  posterior  to  the  optic  chiasm.  The  inner  half  of 
one  and  the  outer  half  of  the  other  eye  are  usually  obscured. 

Color-blindness. — There  is  a  congenital  defect  of  the  retina  in  which  the  indi- 
vidual is  incapable  of  recognizing  certain  colors,  as  red,  green,  and  blue ;  a  little 
more  than  three  per  cent  of  males  are  so  affected.  Of  thirteen  hundred  and  eighty- 
three  men  in  the  emplo}Tnent  of  the  Pennsylvania  Eailroad  Company  examined 
by  Dr.  William  Thomson,  fifty-five  were  absolutely  color-blind.  It  is  less  common 
in  women.  The  usual  method  of  testing  is  that  with  Professor  Holmgren's  colored 
woolen  threads.  If  the  patient  is  wholly  color-blind,  he  will  be  unable  to  differ- 
entiate between  the  principal  colors.  Partial  color-blindness  may  be  detected  by 
a  careful  test  with  the  woolen  threads,  requiring  the  suspected  person  to  match 
to  the  leading  colors  those  which  to  him  appear  of  the  same  or  nearly  the  same 
shades. 


272 


THE   EYE 


Strabismus 

Strabismus,  or  "  squint,"  may  be  convergent  or  divergent.  The  former  is  by- 
far  the  more  frequent  variety,  and  is  usually  observed  in  young  children.  It  re- 
sults from  a  loss  of  the  normal  equilibrium  in  the  muscles  of  the  eye,  and  when 
first  noticed  is  often  intermittent,  appearing  in  one  eye  and  then  the  other  {alter- 
nating). As  a  result  of  prolonged  and  repeated  efforts  at  accommodation  (contrac- 
tion of  the  ciliary  muscle  causing  relaxation  of  the  zonula,  with  consequent  increase 
in  the  antero-posterior  diameter  of  the  lens),  the  internal  rectus  becomes  perma- 
nently shortened. 

The  degree  of  convergence  may  be  determined  by  the  strabismometer  (Fig.  343). 
Let  the  patient  fix  his  vision  on  a  distant  point  directly  in  front  of  him;  place  the 


Fig.  343. — Lawrence's  strabismometer. 


center  of  the  instrument  directly  beneath  the  center  of  the  pupil,  and  measure  the 
distance  from  this  point  to  the  inner  angle  of  the  eye.  The  same  measurement 
on  the  affected  side  will  determine  the  degree  of  convergence  on  that  side. 

Treatment. — Tenotomy  is  indicated  in  convergent  strabismus  for  the  relief  of 
deformity,  as  well  as  for  the  correction  of  vision.     The  prospect  of  a  perfect  result 
is  better  in  recent  cases  than  in  those  of  long  standing,  in  which  the  external 
rectus  has  been  overstretched  and  permanently  weakened.     In  children,  about  the . 
seventh  year  is  the  best  period  for  operation.     Tenotomy  of  the  internal  rectus  is 


Fig.  344. — Von  Graefe's  strabismus-hook. 

thus  done:  The  conjunctiva  is  first  anesthetized  with  cocaine  solution,  and  two 
to  four  minims  may  be  injected  into  and  beneath  the  conjunctiva,  immediately 
about  the  insertion  of  the  muscle.  The  speculum  is  introduced,  and  the  conjunctiva, 
just  on  the  inner  side  of  the  eye,  picked  vip  with  the  forceps  and  divided  with 
the  scissors.  The  strabismus-hook  (Fig.  344)  is  next  carried  into  this  opening 
and  guided  beneath  and  behind  the  tendon  of  the  rectus  internus,  which  is  pulled 


forward  and  divided  at  its  insertion  into  the  sclerotic.  The  hook  should  be  again 
introduced,  to  make  sure  that  a  thorough  division  is  effected.  A  pad  of  cotton 
dipped  in  1)oracic-acid  solution,  held  in  place  by  a  dry  cotton  compress  and  band- 
age, should  be  worn  for  one  or  two  days.  When  strabismus  makes  its  appearance 
in  adult  life,  it  is  usually  due  to  paralysis,  partial  or  complete,  of  one  or  more  of 
the  orbital  muscles.     The  lesion  producing  paralysis  may  be  situated  in  the  brain 


THE  EYE 


273 


or  in  the  orbit.  Disease  of  the  bones  about  the  foramina  of  exit  of  the  nerves  which 
sujDply  these  muscles,  the  presence  of  syphilitic  giimmata,  or  any  neoplasm,  will 
prodvice,  by  jDressure  on  the  nerves  or  muscles,  a  more  or  less  complete  paralysis. 
Eheumatism  is  occasional^  a  cause  of  strabismus. 

In  the  treatment  of  strabismus  due  to  jjaralysis,  operative  interference  is  not 
indicated  until  all  other  remedial  agents  have  been  exhausted  in  vain.  When  oper- 
ation is  demanded,  not  only  should  division  of  the  contracted  muscle  be  efEected 
as  just  described,  but  the  weaker  muscle  may  be  short- 
ened by  advancing  its  insertion. 

Take,  for  example,  the  external  rectus.  Perform 
tenotomy  as  heretofore  described.  A  small  curved 
needle  is  threaded  with  fine  silk  and  carried  from  the 
■ocular  side  out  through  the  divided  muscle  and  con- 
junctiva. Each  end  of  this  double  suture  is  now 
threaded  to  a  curved  needle  and  passed  beneath  and 
through  the  conjunctiva,  coming  out  near  the  margin 
of  the  cornea  and  about  one  eighth  of  an  inch  from 
the  vertical  meridian  of  the  eye  above  and  below 
(Fig.  346).  The  needles  are  cut  away,  and  the  two 
•ends  of  the  lower  threads  tied  together,  at  the  same 
time  that  an  assistant  ties  the  upper  ends.  These 
sutures  are  allowed  to  remain  about  fort^'-eight  hours. 
The  amount  of  shortening  in  the  muscle  advanced  can 
be  increased  b}'  carrying  the  first  needle  farther  back 
through  the  muscle.  In  order  to  get  the  best  possible 
result,  the  shortening  should  be  slightlj'  more  than  appears  necessary  at  the  time 
of  operation. 

EeFKACTION The    OPI-ITHALilOSCOPE  ^ 

By  the  refraction  of  the  eye  we  mean  its  power,  when  in  a  state  of  rest,  of 
bringing  parallel  rays  of  light  to  a  focus.  In  normal  refraction,  or  emmetropia, 
the  focus  for  parallel  rays  is  upon  the  retina  (Fig.  34:7).  When  the  focus  for 
parallel  rays  is  not  on  the  retina,  there  is  said  to  be  an  error  of  refraction.  The 
term  ametropia  includes   all  the   errors   of   refraction.     The   princijjal   forms   of 


Fig.  346. — Advancement  of  the 
rectus.      (De  Wecker.) 


Pig.  347. — Showing  concentration  of  rays  of  light  (a,  &,  c)  on  the  retina  (d)  in  normal  refraction. 

(Swanzy.) 

ametropia  are:  (1)  myopia;  (2)  hypermetropia.  All  the  other  forms  of  ametropia 
are  included  under  the  head  of  astigmatism,  in  which  the  refraction  differs,  in 
■degree  or  kind,  in  opposite  meridians  of  the  same  eye. 

The  difference  in  refraction  of  eyes  is  due  to  their  difference  in  shape.  Wliile 
the  emmetropic  eye  is  nearly  spherical,  the  myopic  eye  is  egg-shaped — too  long 
in  its  antero-posterior  diameter;  and  the  hj^permetropic  eye  turnip-shaped — too 
short  in  its  antero-posterior  diameter.  Thus,  while  the  principal  focus  of  the 
emmetropic  eje  is  upon  the  retina,  that  of  the  hypermetropic  eye  is  behind  the 
retina  (Fig.  348),  and  that  of  the  myopic  eye  in  front  of  it  (Fig.  349). 

Astigmatism  is  usually  due  to  asymmetry,  or  irregularity  of  surface,  of  the 
cornea,  probably  sometimes  to  a  like  condition  of  the  lens.    The  varieties  of  astig- 

'  The  author  desires  to  acknowledge  his  indebtedness  to  his  friend,  Prof.  David  Webster, 
M.D.,  by  whom  this  article  on  Refraction  was  written. 


274  THE   EYE 

matism  are  six  in  number:  (1)  simple  myopic,  (2)  compound  myopic,  (3)  simple 
hypermetropic,  (4)  compound  hypermetropic,  (5)  mixed,  and  (6)  irregular  astig- 
matism. 

In  simple  myopic  and  simple  hypermetropic  astigmatism,  the  principal  focus 
of  one  meridian  of  the  cornea  is  upon  the  retina,  while  the  principal  focus  of  the 


Fig.  348. — Showing  rays  converging  to  focus  (at  a)  behind  the  retina  (fc,  c).     The  hypermetropic  eye 

(Swanzy.) 

opposite  meridian  is  anterior  to  the  retina  or  behind  it,  accordingly  as  the  astig- 
matism is  myopic  or  ly^permetropic. 

In  compound  myopic  astigmatism  all  the  meridians  of  the  eye  are  myopic,  but 
one  of  them  more  so  than  any  of  the  others,  and  the  meridian  at  right  angles  to 
it  less  so  than  any  of  the  others. 

In  compound  hypermetropic  astigmatism  all  the  meridians  of  the  eye  are 
hypermetropic;  but  one  of  them  more  so  than  any  of  the  others,  and  tlie  meridian 
at  right  angles  to  it  less  so  than  any  of  the  others.     In  mixed  astigmatism  one 


Fig.  349. — Showing  concentration  at  (/)  of  rays  of  light  {a,  b)  in  front  of  retina  (c,  d)  in  myopia. 

(Swanzy.) 

meridian  of  the  eye  is  myopic,  while  the  opposite  meridian  is  hypermetropic.  In 
irregular  astiginatism  different  parts  of  the  same  meridian  possess  different  degrees 
of  refraction.  Hence  this  form  of  astigmatism  is  the  only  error  of  refraction, 
which  cannot  be  corrected  by  glasses.    It  is,  in  every  sense  of  the  word,  irremediable. 

It  is  obvious  that  persons  with  emmetropic  eyes,  and  with  unimpaired  accommo- 
dation and  well-balanced  ocular  muscles,  do  not  need  spectacles.  Persons  with  any 
of  the  different  forms  of  ametropia  are  liable  to  become  the  subjects  of  asthenopia 
from  eye-strain.  Such  persons  complain  of  inability  to  use  their  eyes,  pain  in  their 
eyes  and  temples,  headache,  nausea,  and  various  nervous  disorders. 

Hypermetro|)ia  is  congenital,  as  a  rule,  and  is  said  to  be  due  to  an  arrest  of 
development  of  the  globe  in  its  antero-posterior  axis.  It  is  sometimes  the  result 
of  changes  in  the  refractive  media,  as  in  the  hardening  of  the  crystalline  lens  that 
occurs  in  old  age,  or  the  removal  of  the  lens  by  operations  for  cataract. 

Parallel  rays  of  light  passing  through  the  hypermetropic  pupil  do  not  meet  on 
the  retina,  but  converge  toward  a  point  behind  it.  Objects  are  therefore  seen  under 
circles  of  diffusion;  and  such  eyes,  in  order  to  see  distinctly,  contract  their  ciliary 
muscles  sufficiently  to  so  increase  the  convexity  of  the  crystalline  lens  that  the 
focus  will  be  brought  forward  upon  the  retina.  This  act  is  involuntary,  and  pro- 
duces more  or  less  strain  upon  the  eyes.  For  such  persons  the  strongest  convex 
spherical  glasses  should  be  selected  with  which  they  can  distinctly  see  oljjects  dis- 
tant twenty  feet  or  more.     If  the  asthenopie  symptoms  only  accompany  or  follow 


THE   EYE  275 

the  use  of  the  eyes  for  reading  and  other  near  work,  it  may  be  sufficient  to  wear 
the  glasses  only  for  the  near.  But  Avhen  the  asthenopia  symptoms  are  constant, 
and  are  only  aggravated  liy  near  work,  the  glasses  should  be  worn  constantly. 

In  selecting  glasses  for  the  relief  of  asthenopia,  no  matter  what  the  error  of 
refraction,  it  is  always  well  to  examine  the  eyes  with  the  pupil  dilated.  While 
sulphate  of  atropia  is  the  most  reliable  mydriatic,  if  used  in  solution,  sufficiently 
strong  to  paralyze  the  accommodation,  it  incaijaeitates  the  ej^es  for  near  vision  for 
at  least  ten  days. 

When  the  oliject  is  to  ascertain  the  true  refraction  with  as  little  inconvenience 
to  the  patient  as  possible,  it  is  sufficient  for  all  practical  purposes  to  drop  into 
the  eyes  a  few  minims  of  a  three-per-cent  solution  of  homatropine  hydrobromate 
at  intervals  of  fifteen  minutes,  until  seven  or  eight  instillations  have  been  made, 
and  to  test  the  refraction  ten  or  fifteen  minutes  after  the  last  instillation.  If  the 
homatropine  produces  redness  of  the  eyes,  as  is  often  the  case,  this  may  be  relieved 
by  a  single  instillation  of  a  four-per-cent  solution  of  cocaine  hydrochlorate,  which, 
at  the  same  time,  increases  the  effect  of  the  homatropine  in  paralyzing  the  ciliary 
muscle.  The  effect  of  these  mydriatics  passes  off  inside  of  twenty-four  hours.  In 
cases  where  it  is  desirable  that  the  patient  should  have  the  benefit  of  a  prolonged 
rest  of  his  accommodation,  regardless  of  inconvenience,  it  is  better  to  use  the  sul- 
phate of  atropia  (a  one-per-cent  solution). 

In  some  cases  of  asthenopia  from  hypermetrojoia,  glasses  correcting  the  total 
error  of  refraction  are  worn  with  comfort  from  the  start.  In  the  majority  of  cases, 
however,  when  the  accommodation  reasserts  itself,  such  glasses  make  the  eyes  prac- 
tically myopic,  and  the  indistinctness  of 'vision  thus  produced  so  annoys  the  patient 
that  he  rejects  them.  It  is  safer,  therefore,  to  wait  until  the  h}'permetrope  has 
recovered  from  the  effects  of  the  mydriatic,  and  then  to  order  tlie  strongest  convex 
glasses  that  he  can  wear  with  comfort.  When  his  eyes  have  become  accustomed 
to  these,  they  should  be  exchanged  for  stronger  ones,  and  these  changes  should  be 
repeated  at  intervals  of  two  or  three  months  until  the  total  liypermetropia  is  cor- 
rected. After  that  it  is  probable  that  the  patient  will  need  no  further  change  of 
glasses,  and  that  the  relief  of  his  asthenopia  will  be  permanent. 

Myopia  may  be  apparent  or  real.  Ajjparent  myopia  is  due  to  spasm  of  the 
ciliary  muscle,  and  may  be  diagnosticated  from  true  myopia  by  ascertaining  the 
true  refraction  under  the  effects  of  atropia.  Spasm  of  the  ciliary  muscle  is  usu- 
ally the  result  of  overuse  of  the  eyes.  Such  patients  should  be  kept  under  atropia 
for  several  weeks,  wearing  medium  smoked  coquille  glasses  to  protect  the  retina 
from  excessive  light.  When  the  spasm  of  the  ciliary  muscle  fails  to  reassert  itself 
after  the  iise  of  the  mydriatic  is  stopped,  convex  glasses,  correcting  the  hyper- 
metropia,  which  almost  always  exists  in  such  cases,  should  be  substituted  for  the 
coquilles,  and  the  patient  should  be  cautioned  not  to  resume  the  excessive  near 
use  of  his  eyes.  True  myopia  is  the  result  of  the  lengthening  of  the  antero-piosterior 
diameter  of  the  eyeball,  and  is  rarely  congenital.  There  often  exists  a  hereditary 
tendency  to  myopia;  and  it  is  a  matter  of  common  observation,  that  where  the 
father  or  mother  is  myopic  the  children  are  apt  to  develop  the  same  condition 
during  school-life.  Myopia  is  frequently  developed  in  children,  however,  where 
there  is  no  traceable  hereditary  tendency.  It  almost  invariably  first  shows  itself 
during  early  school-life,  and  the  first  intimation  of  it  is  that  the  cliild  fails  to 
see  the  letters  and  figures  on  the  blackboard  across  the  school-room.  It  is  en- 
couraged by  the  use  of  the  eyes  by  insufficient  light  in  a  vitiated  atmosphere,  and 
in  a  stooping  position,  during  the  period  when  the  eyes  are  undergoing  rapid  devel- 
opment along  with  the  other  organs  of  the  body.  It  is  of  the  greatest  importance 
that  it  should  l)e  arrested  as  soon  as  possible ;  for  highly  myopic  eyes  are  nearly 
always  diseased  eyes,  and  are  in  great  danger  of  developing  staphyloma  posticum, 
retinal,  and  choroidal  changes,  floating  bodies  in  the  vitreous,  and  detachment  of 
the  retina.  Myopic  patients  should  be  fitted  with  glasses  at  as  early  a  period  as 
possible,  the  weakest  concave  glasses  being  selected  for  them,  with  which  they  can 
see  distant  objects  distinctly.  They  should  wear  such  glasses  constantly;  by  so 
doing,  arrest  of  development  of  the  ciliary  muscle  will  be  avoided,  as  will  also 
excessive  strain  upon  the  interni.     Attention  to  their  general  health  should  not 


276 


THE   EYE 


be  neo-lected,  and  the  amount  of  use  of  their  e3'es  for  near  work  should  be  limited. 
Their  eyes  should  be  tested  at  least  once  in  six  months,  and  a  careful  record  kept 
of  the  results  of  such  testings,  for  it  is  only  in  this  way  that  we  can  tell  whether 
the  myopia  is  stationgiry  or  progressive,  and,  if  the  latter,  whether  rapidly  so  or 
not.  If  the  myopia  is  increasing  rapidly,  near  work  should  be  entirely  stopped, 
and  the  patient  should  be  put  upon  atropia  and  colored  glasses,  and  turned  out 
into  the  open  air.  Myopia  usually  ceases  to  be  progressive  somewhere  between  the 
ao-es  of  twenty  and  thirty.  Aside  from  all  consideration  of  the  health  of  the  eyes, 
myopes  should  wear  the  correcting  glasses  for  educational  reasons. 

Astigmatism,  especially  when  only  slight  and  correctible  by  an  unequal  con- 
traction of  the  ciliary  muscle,  is  a  prolific  source  of  asthenopia.  When  it  exists 
in  the  higher  degrees,  the  patient  makes  no  attempt  to  correct  it;  sees  indistinctly 
at  all  distances,  and  is  comparatively  free  from  asthenopic  symptoms.  The  slighter 
degrees,  then,  should  be  corrected  with  glasses  for  the  relief  of  asthenopia;  the 
higher  degrees  for  the  purpose  of  procuring  distinct  vision.  Of  course,  in  fitting 
patients  with  glasses  for  the  correction  of  astigmatism,  convex  and  concave  cylin- 


FiG.  350. — Nachet's  trial-set. 


drical  lenses  are  necessary.  For  simple  hypermetropic  astigmatism  that  convex 
cylindrical  glass  should  be  selected  which  brings  the  focus  of  the  hj^permetropic 
meridian  forward  upon  the  retina,  and  this  makes  distinct  vision  possible  without 
an  effort  of  accommodation.  For  simple  myopic  astigmatism  the  concave  cylin- 
drical glass  should  be  selected  which  throws  the  focus  of  the  myopic  meridian  back 
upon  the  retina,  and  thus  renders  the  eye  practically  emmetropic.  For  compound 
hypermetropic  astigmatism  a  convex  spherical  with  a  convex  cylindrical  glass  is 
necessarj',  while  in  compound  myopic  astigmatism  the  error  of  refraction  is  cor- 
rected by  the  combination  of  a  concave  spherical  and  a  concave  cylindrical  glass. 
Mixed  astigmatism  is  corrected  by  a  convex  cylindric  and  a  concave  cylindric  com- 
bined, and  with  their  axes  at  right  angles  to  one  another. 

In  prescribing  glasses  for  astigmatism  the  greatest  care  should  be  taken  to 


THE   EYE  277 

adjust  the  axes  proiDerly.  The  cylindric  trial-glasses  should  always  he  placed  before 
the  eyes  in  trial-frames  made  for  the  purpose,  and  the  direction  of  the  axes  read 
in  degi-ees  from  the  frames.  Ophthalmologists  use  Snellen's  test-types  in  examining 
for  errors  of  refraction,  and  the  cases  of  trial-glasses  made  by  j^achet  (Fig.  350) 
are  as  good  as  any. 

Testixg  foe  Glasses 

For  determining  errors  of  refraction  and  fitting  patients  with  spectacles,  the 
surgeon  should  provide  himself  with  Snellen's  and  Jaeger's  test-types  and  with  a 
case  of  trial-glagses,  including  spherical  and  cylindrical  glasses,  convex  and  con- 
cave, trial-frames  with  the  degrees  of  a  semicircle  marked  upon  them,  etc.  The 
patient  should  be  placed  at  a  distance  of  twenty  feet  from  Snellen's  test-tj'pe,  with 
the  light  shining  upon  the  test-tj'pe  and  not  upon  the  face  of  the  patient.  Each 
eye  should  be  tested  separately,  the  other  being  kept  open  and  covered  with  a 
screen. 

Snellen's  test-type  is  so  constructed  that  the  letters  in  each  line  subtend  an 

angle  of  five  minutes  at  the  distance  marked  in  feet  above  the  line.     The  line 

marked  100  should  therefore  be  read  at  one  hundred  feet;  that  marked  20,  at 

twentj'  feet,  etc.     Vision  is  recorded  fractionally,  the  distance  from  the  test-type 

being  set  down  as  the  numerator,  while  the  number  of  the  line  read  is  set  down 

as  the  denominator.     Thus,  if  a  person  with  his  right  eye  reads  Snellen  Xo.  70 

at  twenty  feet,  the  vision  would  be  recorded  thus :  E.  V.  =:  |-S-.     If  with  his  left 

eye  he  reads  Snellen  Xo.  20  at  twenty  feet,  it  is  recorded  L.  V.  =  f^.     The  vision 

of  the  right  eye  would  be  two  sevenths  of  the  normal,  while  that  of  the  left  eye 

would  be  one,  or  normal.     If  a  patient  reads  ||  with  each  eye,  we  Imow  that  Ms 

vision  is  perfect  in  both  e)^es,  but  still  he  may  be  hypermetropic,  and  straining  his 

accommodation  in  order  to  see  distinctly.     We  should  always  test  such  a  patient 

with  convex  spherical  glasses.     If  the  weakest  glass  blurs  his  vision,  he  laas  no 

manifest  h}^eiTaetropia.     The  vision  and  refraction  of  such  a  patient  should  be 

recorded  thus :     -„   -,^         »„     -r^      t    i-         »„     -n    /  ^       •  \ 

E.  A  .  =  H  ;  E.     L.  A  .  =  ff  ;  E.  (emmetropic). 

If  the  patient  can  read  Snellen  Xo.  20  at  twenty  feet  thi-ough  a  convex  spheri- 
cal glass,  tlie  strongest  one  through  which  he  can  read  it  represents  his  manifest 
hj'permetropia.     Thus — 

E.  V.  =  f^ ;  Hm.  1.75  D.     L.  Y.  =  |-a  ;  Hm.  1.50  D. 

would  mean  that  the  patient  had  perfect  vision  without  a  glass,  or  with  any  convex 
spherical  glass  from  the  weakest  up  to  -)-  1.75  D.,  right  eye,  and  +  1.50  D.,  left  eye; 
but  that  stronger  glasses  than  those  indicated  would  blur  his  vision.  Those  glasses 
should,  therefore,  be  prescribed.  If  the  patient  sees  less  than  fg-,  we  may  suspect 
myopia  or  astigmatism.     For  instance,  the  formula — 

E.  V.  =  ^Vo ;  U  witli  -  4  D.     L.  V.  =  tVtt  ;  M  with  -3D. 
means  that,  without  glasses,  the  patient  sees  ^^  with  his  right  eye,  and  -fo^  with 
his  left  eye,  and  that  —  i  dioptries  is  the  -wealcest  concave  glass  with  wliich  he  can 
read  |f  with  his  right  eye,  and  —  3  dioptries  the  weakest  with  which  he  can  read 
■§-§■  with  his  left  eye."- 

Again,  the  patient  may  be  astigmatic.     Suppose  we  find — 

=^  E.  V.  =  ff ;  1-^  with  4-  1.25  D.  c.  ax.  90°. 
L.  Y.  =  l^j  f^  with  +  1  D.  s.  O  +  1-50  D.  c.  ax.  90°. 
We  have  here  simple  hypermetropic  astigmatism  in  the  right  eye,  and  compound 
hypermetropic  astigmatism  in  the  left.     In  the  right  eye,  the  vision  is  brought  up 
to  -If  by  a  convex  cylindric,  one  and  a  quarter  dioptries,  axis  90° ;  while  in  the  left 
the  combination  of  a  convex  spherical  and  a  convex  cylindrical  is  recjuired. 

1  In  the  dioptric  scale  of  numbering  spectacle-lenses  the  unit  is  a  weak  lens  of  100  centimetres 
focal  length,  or  D.  (one  dioptry).     A  lens  with  focal  length  of  50  cm.  =  (2  D.),  etc.     _  . 

2  This  reads:  Right  vision  equal  JfJ;  fS  with  convex  1.25  Dioptries,  cylindric,  axis  90°._  Left 
vision  equal  fj};  f  j  with  (+)  convex  1  D.  spherical,  (  C  )  combined  with  convex  1.50  D.  cyUndric, 
axis  90°. 


278  THE   EYE 

In  another  case — 

R  V.  -—  -jVu  ;  |-S-  with  —  3.35  D.  c.  ax.  180°. 

L.  V.  =  ^Itj  ;  U  with  -  3.75  D.  s.  C  -  2  D.  c.  ax.  180°. 

Here  we  have  sim23le  myopic  astigmatism  in  the  right,  and  compound  myopic  astig- 
matism in  the  left.  In  mixed  astigmatism  the  refraction  may  be  corrected  and 
the  vision  broixght  up  to  tlie  normal  by  either  of  three  different  combinations  of 
lenses.     Thus — 

K.  Y.  =  fjj  ;  If  with  +  1  D.  c.  ax.  90°  C  -  1  D.  c.  ax.  180°. 
L.  V.  =  -If ;  -H  with  +  3  D.  c.  ax.  90°  C  -  3  D.  c.  ax.  180°. 

The  equivalent  glasses  would  he — 

E.  +  1  D.  s.  C  -  2  D.  c.  ax.  180°. 
L.  +  2  D.  s.  C  -  4  D.  c.  ax.  180°.     Or, 
E.  -  1  D.  s.  C  +  2  D.  c.  ax.  90°. 
L.  —  2  D.  s.  C  +  4:  D.  0.  ax.  90°. 

In  fitting  patients  with  cj'lindric  glasses  the  direction  of  the  axes  is  read  from 
the  degrees  marked  on  the  trial-frames  toward  which  the  axes  f)oint  in  giving  the 
best  vision. 

Presbyopia,  or  old  sight,  is  an  impairment  of  the  accommodation  due  to  the 
grad^ial  hardening  of  the  crystalline  lens,  the  result  of  age.  Persons  who  are 
emmetropic,  or  slightly  hypermetropic,  usually  need  glasses  for  near  purposes  when 
from  forty  to  fort_y-five  years  of  age.  The  higher  degrees  of  hypermetropia  neces- 
sitate the  use  of  glasses  for  reading  much  earlier.  In  the  lower  degrees  of  myopia 
the  use  of  glasses  for  reading  may  be  deferred  considerably  longer,  while  in  the 
higher  degrees  they  may  never  be  needed  at  all.  Presbj^opes,  no  matter  what  their 
refraction,  should  be  suited  with  the  glasses,  generally  convex,  with  which  we  find 
experimentally  they  can  read  most  comfortably.  Generally  the  weaker  convex 
glasses  are  selected  in  the  early  stages  of  presbyopia,  and  these  are  exchanged  for 
stronger  ones  as  the  patient  advances  in  life. 

Heterophoria. — Insufficiency  of  the  extrinsic  ocular  muscles — latent  or  dynamic 
squint. 

When  the  extrinsic  ocular  muscles  are  not  well  Ijalauced,  as  when  the  interni 
are  relatively  stronger  than  the  externi,  or  one  of  the  inferior  recti  weaker  than 
its  fellow  of  the  opposite  side,  there  is  a  tendency  of  one  eye  to  deviate  in  the 
direction  of  the  relatively  stronger  muscle.  If  the  eye  should  actually  deviate, 
diplopia  (double  vision)  would  result,  and  would  be  productive  of  great  annoyance. 
Therefore,  single,  binocular  vision  is  always  maintained  as  long  as  possible,  and 
in  order  to  its  maintenance,  an  extra  innervation  has  to  be  supplied  to  the  weaker 
muscle.  This  constant  strain  causes  asthenopia,  headache,  nervousness,  etc.  In 
some  cases  the  strain  can  be  removed  by  the  use  of  prisms  worn  with  their  bases 
toward  the  weaker  muscles,  alone,  or  combined  witlr  the  lenses  which  correct  any 
existing  error  of  refraction.  But  in  man}^  cases  it  becomes  necessarj^  to  restore 
equilibrium  of  the  muscles  by  a  tenotomy  of  the  stronger  or  a  tendon  resection  of 
the  weaker  muscle. 

The  different  kinds  of  correctible  heterophoria  (tendency  to  deviation  of  the 
visual  lines)  are:  1.  H^'perphoria  (a  tendency  upward  of  one  eye).  2.  Exophoria 
(a  tendency  outward).     3.   Esophoria    (a  tendency  inward). 

In  order  to  ascertain  with  accuracy  the  kind  and  amount  of  heterophoria,  the 
surgeon  should  provide  himself  with  a  j^horometer  (an  instrament  of  precision 
invented  by  Dr.  George  T.  Stevens,  of  New  York),  and  a  set  of  square  prisms, 
of  one  degree  and  upward. 

The  patient  is  seated  facing  a  lighted  candle,  which  is  situated  on  a  level  with 
his  eyes,  and  twenty  feet,  or  more,  distant.  The  horizontal  bar  of  the  phorometer 
is  placed  in  front  of  his  e,yes  and  a  few  inches  away  from  them.  In  a  slot  in  this 
horizontal  bar  is  jjlaced  a  frame  containing  two  prisms  of  four  degrees  to  eight  de- 
grees each,  bases  toward  the  nose,  and  on  looking  at  the  candle  through  these  prisms, 


THE   EYE  279 

the  images  are  thrown  to  the  nasal  side  of  the  macula,  and  the  patient  has  homony- 
mous diplopia.  If  both  inferior  recti  are  of  equal  strength,  and  likewise  both 
superior  recti,  neither  eye  will  deviate  upward,  and  the  two  candles  will  appear 
in  a  horizontal  line,  or  on  a  level.  But  if  one  eye  deviates  upward,  the  image  will 
be  thrown  upon  the  supero-nasal  quadrant  of  the  retina  of  that  e3'e,  and  will  be 
seen  on  a  lower  level  than  that  seen  with  the  other  eye.  The  prism  placed  before 
the  eye  that  sees  the  lower  candle,  base  down,  which  brings  the  candles  on  a  level, 
measures  the  amount  of  hyperphoria. 

'Having  tested  for  hyperphoria,  the  horizontal  prisms  should  be  removed  and 
replaced  by  a  prism  base  dowTi  in  front  of  one  eye.  This  will  produce  vertical 
diplopia  bj'  throwing  the  image  of  the  candle-flame  on  the  retina  below  the  macula, 
so  that  it  will  be  projected  above.  If  the  two  flames  are  seen  in  a  vertical  line, 
there  is  no  insuJSciency  of  the  interni  or  externi.  But  if  the  images  are  homony- 
mous, there  is  insufficiency  of  the  externi ;  and  the  prism,  base  out,  that  makes  them 
vertical,  measures  the  esojjhoria. 

If  the  images  are  crossed,  there  is  insufficiency  of  the  interni;  and  the  prism, 
base  in,  that  makes  them  vertical,  measures  the  exoplioria.  In  making  these  tests, 
the  horizontal  bar  of  the  phorometer  must  be  carefully  adjusted  by  means  of  the 
attached  screw  or  ratchet  and  spirit-level. 

In  order  to  arrive  at  a  more  jiositive  idea  as  to  the  relative  strength  of  the 
ocular  muscles,  it  is  necessary-  to  measure  (1)  the  abduction,  (3)  the  adduction, 
and  (3)  the  sursumduction. 

The  abduction  is  measured  by  the  strongest  jjrism  that  can  be  overcome  by 
the  externi — that  is,  the  strongest  jirism,  base  in,  through  which  the  patient  can 
see  singly  at  twenty  feet  or  more.  In  like  manner,  the  strongest  prisms,  base  out, 
through  which  the  jJatient  has  binocular  single  vision,  measure  the  adduction;  and 
the  strongest  j)rism,  base  down,  over  one  eye,  through  which  the  j)atient  sees  singly, 
measures  the  sursumduction. 

In  hyperphoria  of  one  degree  or  more,  the  superior  rectus  of  the  hyperphoric 
eye  may  be  divided;  in  esophoria  of  two  degrees  or  more,  the  interniis  may  be 
cut;  and  in  exophoria  of  two  degrees  or  more,  the  externus  may  be  snipped.  But 
if  the  surgeon  would  avoid  an  overcorrection,  thus  leaving  the  eyes  in  a  worse 
condition  than  before,  he  must  follow  the  method  advocated  by  Stevens : 

1.  Make  a  small  opening  iu  the  conjunctiva  over  the  tendon  to  be  cut. 

2.  Seize  the  center  of  the  tendon  with  delicate  but  strong  forcepis,  made  for 
the  purpose,  and  buttonhole  it  with  delicate  probe-pointed  scissors. 

3.  Introduce  one  blade  of  the  same  scissors  between  the  tendon  and  the  sclera 
and  the  other  blade  between  the  tendon  and  the  conjunctiva,  and  cut  transversely 
to  one  border  of  the  tendon,  and  then,  reversing  the  scissors,  cut  transversely  to 
the  other  border  of  the  tendon. 

4.  The  eyes  should  now  be  tested  with  prisms,  and  if  the  heterophoria  is  not 
nearly  corrected,  the  scissors  may  be  again  introduced  and  the  loosening  up  of 
the  insertion  be  carried  a  little  further.  Thus  by  cutting  cautiously,  a  little  at 
a  time,  and  then  testing  with  candle  and  prisms  to  ascertain  how  much  effect  has 
been  obtained,  it  is  not  difficult  for  the  dexterous  02)erator  to  correct  the  deviation 
with  consideraljle  accuracy.  N"o  surgeon  should  undertake  these  operations  with 
the  ordinary  clums}'  instruments  in  vogue.  The  necessary  instruments  particularly 
adapted  to  the  purpose,  and  to  tendon-resection,  are  made  by  Messrs.  Tiemann 
&  Co.,  of  jSTew  York.  Tendon-resection  is  practiced  in  cases  where  the  heterophoria 
is  too  great  to  be  corrected  by  a  graduated  tenotomy  of  the  stronger  muscle  with- 
out limiting  the  excursion  of  the  eye  in  that  direction.  In  such  cases  it  is  better 
to  partly  correct  the  deviation  by  tenotomy  and  to  correct  what  remains  by  tendon- 
resection  of  the  weaker  muscle.  In  performing  this  operation,  by  Stevens'  method, 
the  tendon  is  divided  as  in  graduated  tenotom_y.  A  delicate  hook  is  then  slipped 
beneath  and  caught  into  the  under  surface  of  the  divided  tendon  which  is  now 
drawn  out  of  the  conjunctival  aperture  and  caught  some  lines  from  its  extremity 
with  delicate  fixation-forceps.  A  small,  very  sharp,  curved  needle,  armed  with  a 
fine  silk  thread,  is  now  passed  through  the  muscle  from  without  inward,  as  far 
back  as  the  operator  thinks  necessary,  and  then  the  portion  of  the  muscle  anterior 


280 


THE  EYE 


to  the  needle  is  excised  with  scissors.  The  needle  is  then  carried  through  the  stump 
of  the  insertion  of  the  muscle,  including  the  capsule  of  Tenon  and  overlying  con- 
junctiva, and  the  thread  drawn  through  and  loosely  tied. 

The  jDatient  should  now  be  placed  in  the  position  for  testing  with  jarisms,  and 
the  knot  drawn  just  tight  enough  to  correct,  or  slightly  overcorreet,  the  deviation. 
In  both  these  operations  the  lids  may  be  held  open  by  a  speculum,  an  elevator,  or 
the  fingers  of  an  assistant.  The  stitch  may  be  removed  at  the  end  of  three  or 
four  days.  N"o  after-treatment  is  required,  as  there  is  rarely  any  inflammatory 
reaction. 

Tenotomy  and  tendon-resection  for  the  correction  of  heterophoria  should  be 
resorted  to  only  after  all  other  means  for  the  relief  of  asthenopia  have  been  ex- 
hausted. 

Ophthalmoscopy 

The  general  practitioner  should  familiarize  himself  with  the  use  of  the  ophthal- 
moscope suificiently  to  te  able  to  diagnosticate  gross  lesions  of  the  globe  situated 
posterior  to  the  crystalline  lens.  He  should  provide  himself  with  an  ophthal- 
moscope with  tilting  mirror  and  convex  and  concave  lenses  ranging  from  one  to 
twenty  dioptrics.  The  pupils  should  be  dilated  with, 
homatropine  or  cocaine,  two-per-cent  solution  in. 
either  case.  The  patient  should  be  seated  in  a 
darkened  room,  with  a  lamp  placed  on  a  level  with 
the  eye  to  be  examined,  a  little  behind  and  to  one 
side.  The  observer  then  rests  the  ophthalmoscope 
against  the  inner  angle  of  his  orbit  and  throws  the 
light  into  the  eye  with  the  mirror,  at  the  same  time 
looking  into  the  pupil  through  the  aperture  in  the 
mirror.  He  thus  gazes  at  the  papillary  area  while 
the  patient  looks  up,  down,  right,  and  left.  If  the 
reflex  from  the  pupil  is,  in  all  positions  of  the  eye, 
of  a  uniform  clear  pinkish  or  reddish  color,  it  is 
to  be  inferred  that  there  are  no  gross  lesions  of  the 
refractive  media.  If  the  red  reflex  from  the  fun- 
dus is  interrupted  by  dark  spots,  there  are  opacities 
of  the  media,  and  the  surgeon  must  proceed  to  lo- 
cate them.  If  they  move  while  the  eye  is  fixed, 
they  are  floating  bodies  in  the  vitreous.  If  they 
move  with  the  eye  and  stop  when  the  eye  stops, 
they  are  opacities  either  of  the  cornea  or  of  the 
crystalline  lens.  If  of  the  cornea,  they  will  be  seen 
by  oblique  illumination.  This  is  also  true  of  opac- 
ities situated  on  the  anterior  capside  and  in  the 
front  portions  of  the  crystalline  lens.  If  in  the 
posterior  portions  of  the  lens,  they  will  appear  to 
move  in  an  opposite  direction  to  the  eye.  Opacities 
in  the  periphery  of  the  lens  are  seen  only  when  the  eye  is  so  turned  that  the 
observer  looks  through  the  pupil  very  obliquely.  For  more  minute  examination 
of  any  opacity  already  discovered,  the  observer  should  turn  on  over  the  aperture  of 
his  ophthalmoscope  a  -\-  10.  D.,  and  approach  the  eye  to  within  its  focal  distance, 
about  four  inches.  In  this  way  he  will  obtain  a  greatly  magnified  view.  In  higli 
degrees  of  myopia  and  hypermetropia  pigment  patches  in  the  fundus  may  be  mis- 
taken by  the  novice  for  opacities  of  the  media.  These  are  excluded  by  seeing  them 
in  their  true  position  while  examining  the  fundus. 

There  are  two  methods  of  examining  the  fundus:  (1)  The  indirect,  (S)  the 
direct. 

In  examining  the  eye  by  the  indirect  method,  the  observer  interposes  a  two- 
inch  or  two-and-a-half-inch  lens  between  his  ophthalmoscope  and  the  patient's  eye, 
at  about  its  focal  distance  from  the  eye,  his  own  eye  being  twelve  to  fifteen  inches 
In  this  manner  he  gets  an  inverted  image  of  the  fundus,  magnified  some 


Fig.  351. — ^Loring's  student's 
ophthalmoscope. 


THE   EYE 


281 


three  or  four  diameters.     By  directing  tlie  patient  to  look  successively  in  different 
directions,  lie  thus  easily  scans  the  whole  fundus. 

In  using  the  direct  method,  the  observer  approaches  his  eye  with  the  ophthal- 
moscope as  close  as  possible  to  the  eye  he  is  examining,  often  touching  the  brow 
or  nose  of  the  patient  with  his  in.:trument.  In  this  way  he  sees  only  a  small  portion 
of  the  fundus  at  a  time,  but  that  is  in  its  true  position  and  is  magnified  some 
seventeen  diameters,  more  or  less.  The  examined  eye  being  myopic,  he  must  turn 
on  the  iveakest  concave  lens  with  which  he  can  see  the  fundus  distinctly;  and  this, 
while  it  enables  him  to  see  the  fundus  clearly,  at  the  same  time  measures  the  amount 
of  myopia.  If  the  patient  is  hypermetropic  in  a  moderate  degree,  tlie  fundus  will 
be  well  seen  without  any  lens;  but  if  the  observer  would  estimate  the  amount  of 
hypermetropia,  he  must  turn  on  the  strongest  convex  lens  through  which  he  can 
see  the  fundus  distinctly.  In  astigmatism  only  one  meridian  of  the  fundus  is 
seen  distinctly  at  a  time,  the  opposite  meridian  being  seen  through  a  stronger  or 
weaker  lens.  If  the  observer  has  an  error  of  refraction,  he  must  take  it  into  account 
in  estimating  refraction  with  the  ophthalmoscope.  Some  of  the  grosser  lesions  to 
be  looked  for  by  the  surgeon  are: 

1.  Optic  Neuritis. — Here  the  ophthalmoscopic  appearances  vary.  In  the  milder 
cases  only  the  nasal,  or  upper,  or  lower,  border  of  the  disk  is  obscured  by  swelling, 
while  in  the  severer  cases  the  whole  papilla  is  greatly  swollen  and  its  outline  en- 
tirely obliterated.  The  retinal  vessels  are  tortuous,  while  the  veins  are  enlarged 
and  the  arteries  are  either  of  normal  size  or  diminished.  There  may  or  may  not  be 
ecchymoses  upon  the  disk  or  in  the  retina.  Rarely  the  central  vision  and  visual  field 
are  perfect.  In  most  cases,  however,  both  are  impaired,  and  often  vision  is  reduced 
to  perception  of  light.  In  optic  neuritis  or  "  choked  disk  "  of  both  eyes  intracranial 
tumors  should  always  be  suspected.  Optic  neuritis  may,  however,  depend  on  a 
variety  of  causes,  such  as  kidney  disease,  lead-poisoning,  meningitis,  syphilis,  etc. 

2.  Atrophy  of  the  Optic  Nerve  is  recognized  by  the  paleness  of  the  optic  disk 
and  the  smallness  of  the  retinal  blood  vessels.  It  may  be  consecutive  to  optic  neu- 
ritis, or  it  may  be  ushered  in  as  "  primary  "  atrophy.  Therefore  the  conditions 
which  produce  optic  neuritis  should  be  sought  in  cases  of  atrophy.     It  frequently 


Fig.  352.  —  Ophthalmoscopic  appearance  of 
healthy  fundus  in  a  person  of  very  fair  com- 
plexion. Scleral  ring  well  marked.  Left  eye, 
inverted  image.      (Weclier  and  Jaeger.) 


Fig.  353. — Ophthalmoscopic  appearance  of  se- 
vere recent  papillitis.  Several  elongated 
patches  of  blood  near  border  of  the  central 
inflammatory  area.  (After  Huglilings  Jack- 
son and  Nettleship.) 


occurs  in  poisoning  by  tobacco  and  alcohol,  and  is  often  a  symptom  of  progressive 
locomotor  ataxia.     It  is  found  in  advanced  stages  of  retinitis  pigmentosa. 

3.  Retinitis  is  distinguished  by  bright  or  whitish  patches  in  the  retina.  When 
these  arrange  themselves  about  the  macula  lutea  in  a  stellate  form,  the  cause  is 
generally  found  to  be  kidney  disease.  They  are  often  accompanied  by  retinal 
hsemorrhages.     Diabetes  and  syphilis  are  among  the  other  causes  of  retinitis. 


282  THE   EYE 

4.  Choroiditis  is  Ioiotto  by  wjiite  patches  iu  the  fundus,  generally  bordered 
irregularly  Avith  black  pigment,  and  with  the  retinal  vessels  passing  over  them. 
The"cause  is  often  obscured.     It  is  sometimes  due  to  syphilis. 

5.  Glaucoma  simplex  is  always  characterized  by  excavation,  or  cupping  of  the 
optic  disk.  The  retinal  vessels  appear  to  end  abruptly  at  the  discal  border.  The 
bottom  of  the  excavation  can  be  seen  through  a  sufficiently  strong  concave  lens. 
Around  the  disk  is  a  ring  of  choroidal  atrophy  exposing  the  white  sclera.  There 
is  often  j^ulsation  of  the  retinal  arteries.  Central  vision  is  usiially  impaired,  and 
the  visual  field  limited,  esisecially  on  the, nasal  side. 


CHAPTER    XIII 


The  Auricle. — Wounds  of  the  auricle  should  ]je  treated  with  the  view  of  pre- 
venting the  least  possible  deformity.  Lacerations  of  the  lobule,  even  of  long  stand- 
ing, may  be  corrected  by  paring  the  edges  and  uniting  them  by  fine  linen  or 
horsehair  sutures  carried  directly  through  all  the  tissues  of  this  organ.  Cocaine 
infiltration  will  secure  perfect  an»sthesia  in  practically  all  the  operations  upon 
the  auricle. 

Drooping  of  the  ears  may  be  corrected  by  proper  care  in  infancy,  strapping  the 
auricle  against  the  scalp  by  means  of  a  light  elastic  band  carried  around  the  fore- 
head and  occiput.  In  extreme  cases  it  may  be  necessary  to  excise  an  oval-shaped 
piece,  including  the  entire  thickness  of  the  cartilage  from  the  posterior  surface  of 
the  concha,  leaving  the  anterior  cutaneoiis  surface  uncut.  It  is  advisable  to  make 
a  small  section  at  first  and  insert  trial  sutures,  gradually  enlarging  the  wound, 


Fig.  354.— (.\fter  Reeves.) 


Fig.  355.— (After  Reeves.) 


imtil  the  proper  correction  is  secured.  In  children  this  operation  necessitates  ether 
narcosis. 

11)/ pert ro pin/  of  either  one  or  both  auricles  may  be  corrected  by  excision  of  a 
triajigiilar  jiicce,  as  shown  in  Figs.  354:  and  355. 

Adhesion  of  the  auricle  to  tlie  scalp  requires  to  be  freed  by  dissection,  and  the 
raw  surfaces  covered  by  transplantation  of  skin  with  healthy  epidernris. 

Benign  neoplasms  of  the  auricle  are  occasionally  observed  at  or  near  the  tragus. 
They  are  chietly  cartilaginous,  and  should  be  clipped  ofE  with  the  scissors,  under 
cocaine  anesthesia. 

Angeioma  may  be  cured  without  incision  liy  carefully  injecting  the  vascular  area 
with  a  few  minims  of  water  at  a  very  high  temperature,  by  the  author's  method. 

Epithelioma  of  this  organ  occurs  usually  along  the  upper  border,  and  is  not 
infrequently  caused  by  frostbite.  Taken  early  it  is  readily  cured  by  the  application 
of  Marsden's  paste.     (See  Epithelioma.) 

A  not  infrequent  cutaneous  disease  of  the  outer  ear  (intertrigo)  occurs  chiefly 
in  children,  and  is  caused  by  the  uncleanly  habit  of  wearing  a  tight-fitting  cap 

283 


284 


THE   EAR 


or  bonnet  continuously  over  the  ears,  jDlastering  the  auricles  against  the  scalp,  and 
resulting  in  excoriations  which  become  infected.  Correction  of  the  habit,  washing 
with  1-3000  mercuric-chloride  solution  once  or  twice  daily,  and  the  application  of 
an  aseptic  drying  powder  will  efEeet  a  cure. 

The  External  Auditory  Canal. — In  adults  the  length  of  this  canal  is  about  one 
and  a  half  inches,  of  which  the  inner  five  eighths  of  an  inch  is  bony,  the  remaining 
portion  cartilaginous.  The  general  direction  of  the  cartilaginous  portion  is  up- 
ward, backward,  and  inward,  while  that  of  the  bony  portion  is  downward,  forward. 


Fig.  336. — Sextou's  hard-rubber  double  probe. 

and  inward.  In  order  to  straighten  the  canal  in  examination,  it  is  necessary  to 
draw  upon  the  auricle  upward  and  backward. 

In  infants  the  upper  and  lower  walls  are  in  contact. 

The  drum  is  placed  obliquely  to  the  axis  of  the  meatus,  appearing  as  a  continu- 
ation of  the  upper  and  posterior  walls.  In  other  words,  the  superior  and  posterior 
margins  of  the  membrane  are  nearer  the  orifice  of  the  meatus  than  the  inferior 
and  anterior. 

To  examine  the  deeper  ear  satisfactorily,  a  strong  light  is  essential.  The  order 
of  preference  is  the  electric  arc,  the  Argand  or  Welsbach  gas-burner,  and  the 
duplex  coal-oil  lamp.     Unless  direct  electric  illumination  is  employed,  a  reflecting 


forehead  mirror  is  necessary.    That  in  general  use  has  a  focal  distance  of  eight  to 
ten  inches.     Aural  specula  should  be  made  of  thin  polished  metal. 

The  patient  should  be  seated  with  the  head  resting  firmly  against  the  back  of 
the  chair,  the  affected  ear  turned  toward  the  surgeon,  who  should  occupy  a  posi- 
tion slightly  to  one  side.  The  light  should  be  on  the  left  of  the  examiner,  and 
slightly  above  the  horizontal  plane,  passing  through  the  ear  to  be  examined.  The 
condition  of  the  canal  should  be  carefully  studied  before  the  speculum  is  intro- 
duced. The  auricle  should  be  grasped  firmly  at  its  upper  posterior  margin  between 
the  third  and  fourth  fingers  of  the  left  hand,  and  traction  made  upward,  outward, 
and  backward.  In  examining  the  right  ear,  the  hand  lies  behind  the  auricle;  for 
the  left,  above  and  anterior  to  it.  The  speculum  is  held  between  the  left  thumb 
and  index-finger,  the  auricle  being  grasped  between  the  third  and  fourth  fingers  of 


Fig.  35S. — Sexton's  double  ear-liook,  to  extract  foreign  bodies. 


the  same  hand.  In  this  position  the  speculum  is  carried  in  gradually  by  rotation 
upon  its  axis.  It  should  not  be  passed  beyond  the  cartilaginous  canal,  and  should 
expose  without  stretching  the  meatus.  As  the  superior  wall  is  followed  inward, 
there  will  be  seen  just  below  the  center  of  the  line  marking  its  inner  termination 
a  prominent  projection,  white  or  grayish-white  in  color,  having  the  appearance  as 
though  the  soft  parts  covering  it  were  pushed  upward  into  the  lumen  of  the  canal. 
This  is  the  short  process  of  the  malleus,  the  position  of  which  changes  but  little, 
no  matter  how  much  the  system  of  ossicles  may  be  displaced  under  abnormal 


THE  EAR 


285 


conditions.  On  account  of  its  rich  vascular  supplj',  it  often  resists  extensive  caries 
of  the  tympanic  wall  and  of  the  ossiculaj.  Extending  downward,  and  somewhat 
backward  from  this  point  through  the  middle  of  the  membrane  as  far  as  its  center, 
the  handle  of  the  malleus  is  recognized.  The  flattened  termination  of  the  handle 
at  the  center  of  the  membrane  is  known  as  the  umbo. 

Between  the  short  process  of  the  malleus  and  the  superior  wall  of  the  meatus, 
the  membrana  tympana  presents  a  distinctly  triangidar  form,  the  apex  being  at 
the  short  process,  the  sides  of  the  triangle  diverging  to  lose  themselves  in  the 
superior  walls  of  the  canal.  The  sides  of  this  triangle  are  clearly  marked,  and  this 
portion  of  the  drum  membrane  is  known  as  the  membrana  flaccida,  or  Shrapnell's 
membrane. 

Should  the  meatus  be  hairy,  these  may  be  made  to  adhere  closely  to  the  wall 
of  the  canal  by  applying  vaseline  on  a  cotton-ti])ped  probe. 


Fio.  359. — Sexton's  snare 


Lesions  of  the  External  Auditory  Meatus. — When  inflammation  is  present,  the 
exact  location  of  infection  should  be  determined,  carefully  watched,  and  freely 
incised  upon  the  first  indication  of  the  retention  of  pus,  and  the  canal  irrigated 
with  1-5000  warm  mercuric-chloride  solution.  Cocaine,  af)plied  locally  or  by  infil- 
tration, entering  the  needle  from  the  outside  skin,  will  secure  perfect  angesthesia. 

Not  infrequently,  certain  vegetable  parasites  lodge  and  proliferate  in  this  canal. 
They  may  be  recognized  by  the  microscope,  and  are  almost  always  associated  with 
partial  or  complete  occlusion  of  the  meatus  by  aggregations  of  epithelium,  sebaceous 
crusts,  etc.  In  chronic  cases,  the  periosteum  lining  the  bony  portion  of  the  canal 
may  become  involved  and  thickened.  A  thorough  cleansing  with  the  dull  curette 
and  repeated  irrigation  with  1-5000  mercuric-chloride   solution  in  fifty-per-cent 


Fig.  360. — Politzer's  tympanum  perforator,  angular. 


alcohol  will  suffice,  while  sterile  vaseline  or  olive  oil,  applied  once  or  twice  daily, 
will  allay  local  irritation  (Dench). 

Impacted  cerumen  is  best  removed  by  irrigation  with  a  lukewarm  solution  of 
1-8000  mercuric  chloride.  If  the  entire  meatus  is  filled,  an  opening  should  be 
carefully  made  by  a  small,  dull-pointed  instrument,  so  that  the  fluid  may  be  thrown 
through  this  behind  and  around  the  mass,  to  soften  and  force  it  out. 

Foreign  bodies  may  be  removed  preferably  by  irrigation  through  a  delicate 
pipette  carefully  introduced  beyond  the  foreign  substance.  It  is  at  times  necessary 
to  put  the  patient  in  complete  narcosis  to  efl^ect  the  removal  without  injury  to 
the  drum  membrane.  In  exceptional  instances,  where  the  canal  is  abnormally 
small,  it  may  be  necessary  to  perform  the  operation  advised  by  Dench:  Under 
strict  asepsis  an  incision  is  made  from  just  below  the  insertion  of  the  lobule,  upward 
along  the  line  of  attachment  of  the  auricle  to  a  point  just  above  the  meatus,  and 
then  forward  as  far  as  the  lielix ;  the  fibro-cartilaginous  canal  is  then  loosened  from 
its  attachment  by  means  of  the  periosteum  elevator,  the  instrument  being  applied 


286  THE   EAR 

first  below  and  then  behind,  the  superior  wall  being  detached  last.  In  the  same 
way  the  periosteum  of  the  canal  is  separated  from  the  bone,  and  the  fibro-carti- 
laginous  tube  is  divided  transversely  as  near  the  drum  memlarane  as  possible. 

This  anterior  flap,  consisting  of  the  auricle  and  the  soft  parts  of  the  meatus, 
is  turned  forward,  and  entrance  is  thus  gained  to  the  bony  meatus,  and  the  foreign 
body  may  be  extracted  at  once  after  the  flap  has  been  turned  forward.  In  case  the 
object  is  found  so  firmly  fixed  in  the  canal  that  efforts  at  extraction  are  still  futile, 
the  lumen  of  the  meatus  can  he  enlarged  with  a  chisel  by  carefully  chipping  away 
the  bone  from  the  posterior  wall  until  suificient  space  is  obtained.  It  is  better  to 
enlarge  the  passage  bj'  the  removal  of  a  portion  of  the  osseous  wall  than  to  attempt 
to  extract  the  body  by  forcible  manipulation.  The  wound  is  closed  with  silk  sutures 
and  a  small  drainage-tube  inserted  through  the  canal.  Repeated  antiseptic  irriga- 
tions are  advised. 

Bony  new  growiks  from  the  osseous  canal  require  no  special  consideration. 
They  should  be  removed  by  the  most  convenient  method  of  approach. 

Wounds  of  the  membrana  iympani,  whether  incised  or  lacerated,  should  be  made 
aseptic  by  the  local  application  to  the  membrane  of  an  alcoholic  solution  of 
bichloride  of  mercury,  1-3000. 

Inflation,  of  the  Tympamun. — In  order  to  test  the  permeability  of  the  Eusta- 
chian tube,  and  the  normal  mobility  of  the  membrana  tympani,  as  well  as  to  recog- 
nize the  presence  of  liquid  (serum  or  pus)  in  the  middle  ear,  the  following  methods 
of  inflation  may  be  practiced : 

1.  Close  the  nostrils  and  mouth,  and  have  the  patient  attempt  to  force  air 
through  the  nostrils.  If  the  tube  is  permeable,  the  air  will  enter  the  middle  ear 
and  act  upon  the  drum. 

2.  Politzer's  air-bag  consists  of  a  rubber  bulb  attached  to  a  tube,  with  a  nozzle 
to  be  inserted  in  one. nostril,  the  other  being  tightly  closed.  The  lips  are  firmly 
compressed,  and  the  patient  is  directed  to  swallow  in  order  to  throw  the  soft  palate 
firmly  against  the  posterior  pharyngeal  wall,  and  at  this  moment  the  bag  is  suddenly 
compressed,  forcing  the  air  into  the  pharyngeal  vault  and  through  the  Eustachian 
tube. 

3.  By  far  the  most  satisfactory  method  is  through  the  Eustachian  catheter 
(Fig.  361),  which  shoidd  be  made  of  pure  silver,  as  this  is  more  flexible.  To  the 
expanded  outer  end  of  the  catheter  a  rubber  tube  is  attached  before  its  introduction. 
The  other  end  of  this  rubber  tube  is  attached  to  an  ordinary  atomizer  bulb.     "  The 


m 


©  ©  ©  ©  ^ 

-The  Eustachian  catheter. 


inflating  bulb  is  held  in  the  palm  of  the  right  hand,  while  the  catheter  is  grasped 
lightly  between  the  thumb  and  index  and  middle  fingers  of  this  hand.  The  patient 
should  be  seated  in  a  chair  with  a  high  back,  the  head  inclined  forward  slightly, 
while  he  shoidd  close  the  lips  tightly  and  breathe  slowly  through  the  nostrils.  The 
operator,  either  standing  or  sitting  at  the  right  of  the  patient,  tilts  the  tip  of  the 
patient's  nose  upward  with  the  ball  of  the  left  thumb,  the  index  and  middle  fingers 
resting  upon  the  nose  just  below  the  bridge.  From  this  moment  the  left  hand  is 
not  removed  from  the  patient's  nose  until  inflation  has  been  accomplished  and  the 
catheter  has  been  removed.  The  tip  of  the  nose  being  elevated,  the  extremity  of 
the  catheter  is  introduced  into  the  nostril  (Fig.  362)  ;  as  soon  as  the  instrument 
has  passed  the  slight  ridge  at  the  nasal  orifice  the  operator  carries  the  hand  holding 
the  instrument  upward  until  the  catheter  assumes  a  horizontal  position.  In  this 
position,  with  the  tip  kept  constantly  upon  the  floor  of  the  nasal  cavity,  the  catheter 
is  passed  directly  backward  through  the  inferior  meatus  until  the  posterior  pharyn- 
geal wall  is  encountered  (Fig.  363) ;  it  is  then  drawn  forward  about  three  eighths 
or  one  fourth  of  an  inch,  and,  remembering  that  the  guide  ring  on  the  shaft  indi- 
cates the  direction  in  which  the  pharyngeal  extremity  points,  the  instrument  is 
rotated  upon  its  long  axis  until  the  ring  points  almost  directly  outward  toward 


THE  JEAR 


287 


the  side  to  be  inflated.  The  hand  is  then  elevated  a  little  and  carried  slightly 
toward  the  opposite  ear,  causing  the  pharyngeal  extremity  of  the  instrument  to 
descend,  and  at  the  same  time  to  press  lightly  against  the  lateral  pharyngeal  wall. 


Fig.  362. — Introduction  of  the  Eustachian  cathe- 
ter (first  step). 


Fig.  363. — Introduction  of  the  Eustachian  cathe- 
ter (second  step). 

By  drawing  the  catheter  a  little  out- 
ward, the  tip  will  be  felt  to  impinge 
upon  the  posterior  lip  of  the  tube; 
it  is  to  be  drawn  over  this,  the  tip 
being  turned  slightly  downward,  if  necessary,  to  effect  this  without  undue  force. 
As  soon  as  the  operator  knows  by  the  sense  of  touch  that  the  prominent  pos- 
terior lip  has  been  passed,  the  catheter  is  rotated  upon  its  long  axis  until  the 
guide  ring  points  upward  and  outward  toward  the  ear, 
while  at  the  same  time  the  outer  extremity  of  the  in- 
strument is  moved  toward  the  opposite  side,  thus  push- 
ing the  pharyngeal  extremity  well  into  the  mouth  of 
the  tube.  When  carefully  placed,  the  sense  of  fixation 
imparted  to  the  hand  is  unmistakable.  At  this  junc- 
ture the  left  thumb  is  moved  so  as  to  pass  beneath 
the  catheter  and  support  it.  The  instrument  is  thus 
held  firmly  against  the  margin  of  the  nostril,  by  the 
thumb  below  and  the  first  three  fingers,  resting  upon 
the  bridge  of  the  nose,  above  (Fig.  36-1) ;  at  the  same 
time  the  tip  of  the  nose  is  pressed  upward  as  before. 
The  right  hand  is  now  free  to  compress  the  bulb,  forcing 
the  air  through  the  catheter  into  the  middle  ear,  its  en- 
trance being  recognized  by  sounds  heard  through  the 
auscultation  tube."     (Bench.) 

A  soft-rubber  tube,  with  a  proper  tip  at  each  end,  is  inserted,  one  into  the 
meatus  of  the  patient,  the  other  into  that  of  the  examiner.  When  the  bulb  is 
compressed,  if  the  air  enters  there  is  a  short  click  or  sound  of  impact  conveyed 
to  the  surgeon's  ear  as  the  drum  is  pushed  out.  If  the  middle  ear  contains  fluid, 
instead  of  the  "click"  there  is  heard  at  irregular  intervals  a  series  of  sharp, 
crackling,  or  churning  rales.  The  quality  of  these  rales  suggests  the  nature  of  the 
fluid.^  If  high-pitched,  the  fluid  is  watery  or  serous;  if  low  in  pitch,  it  is  thick — 
probably  purulent.  Should  the  cavity  of  the  tympanum  be  overdistended,  no 
crepitation  is  heard,  but  the  ■  impact  sound,  though  distant  and  indistinct,  is 
observed  just  as  the  current  of  air  through  the  tube  strikes  the  contained  fluid. 

A  perforation  of  the  drum  is  indicated  by  a  high-pitched,  whistling  sound  as 
the  air  escapes  through  the  rent. 

At  times  a  deformity  of  the  septum  may  render  it  impossible,  even  by  the  use 
of  adrenalin  and  cocaine,  to  introduce  the  catheter  through  the  lower  meatus.    The 

'  In  old  persons  in  whom  adhesions  have  occurred  this  crackling  sound  is  practically  lost. 


:.  364.  —  Introduction  of 
the  Eustachian  catheter 
(the  instriunent  fixed  in 
the  mouth  of  the  tube). 
(After  Dench.) 


288 


THE   EAR 


curve  of  the  instrument  may  be  changed  to  conform  to  the  route  through  the  middle 
meatus  or,  in  extreme  cases,  through  the  opposite  nostril.  Failing  in  all  attempts, 
the  Politzer  method  may  be  substituted.  The  employment  of  a  proper  solution  of 
cocaine,  usually  ten  per  cent,  not  only  contracts  the  swollen  mucous  membrane, 


Fig.  365. — Vertical  section  showing  the  inferior  meatus  and  posteriorly  the  elliptical  orifice  of  the 
Eustachian  tube  and  its  relation  to  the  posterior  wall  of  the  pharynx.      (After  Dench.) 

leaving  more  space  for  inspection  and  the  p)assage  of  the  instrument,  but  at  the 
same  time  lessens  the  pain  of  the  operation,  which  should  always  be  done  with 
gentleness  and  skill.  Applying  the  spray  will  deaden  the  sensibility  of  the  meatus, 
while  a  small  pledget  of  cotton,  moistened  in  the  cocaine  solution  and  passed 
through  the  inferior  meatus  on  a  probe  properly  curved  to  reach  the  orifice  of  the 
tube,  will  render  the  whole  procedure  practical  Ij'  painless.  If  necessary,  the  con- 
tiguous surfaces  of  the  j^harynx  may  also  be  touclaed  with  this  solution.  In  treating 
a  patient  for  the  first  time,  the  susceptibility  to  cocaine  absorption  should  be 
cautiously  determined. 

When  catheterization  is  clumsily  done  there  is  some  danger  from  emphysema, 
due  to  air  forced  underneath  the  mttcous  surfaces. 

Very  frequently  patients  will  complain  of  dizziness  as  the  air  is  forced  in.  They 
should  be  forewarned  of  this  and  assured  that  there  is  no  need  for  alarm.  It 
should  not  be  forgotten  that  the  drum  of  the  ear  has  been  ruptured  by  too  great 
pressure,  especially  in  the  use  of  the  Politzer  apparatus. 

On  account  of  the  difficulties  in  the  way  of  catheterization  of  the  tube  in  chil- 
dren, the  Politzer  bulb  is  preferable.  Employed  for  diagnostic  purposes,  the  meatus 
of  the  opposite  ear  should  be  stopped  with  the  finger,  so  that  the  only  sound 
conveyed  to  the  ear  of  the  operator  will  be  from  the  affected  tympanum.^ 

1  A  careful  examination  of  the  nose,  nasopharynx,  and  pharynx,  is  an  essential  feature  of  the 
study  of  the  condition  of  the  middle  ear. 


THE   EAR 


289 


Myringotomy. — The  technic  of  the  operative  procedure  upon  the  drum  mem- 
brane under  varying  conditions  is  given  I33'  Prof.  E.  B.  Dench  as  follows: 

"  The  site  of  election  for  perforating  the  drum  membrane  varies  according  to 
the  manifestations  in  each  particular  case.  If  fluid  is  to  be  evacuated  the  incision 
should  commence  at  the  most  prominent  point,  and  should  extend  either  upward 
or  downward  through  the  bidging  portion.  If  the  bulging  involves  chiefly  the  upper 
part  of  the  drum  membrane,  the  knife  should  be  carried  into  the  canal  with  the 
cutting  edge  upward.  Its  point  is  entered  at  the  apex  of  the  tumefaction,  and 
carried  rapidly  through  the  drum  imtil  it  impinges  upon  the  internal  tympanic 
wall,  after  which  it  is  made  to  cut  upward  toward  the  periphery  as  far  as 
may  seem  necessary  (Fig.  366).  As  the  most  prominent  region  is  almost 
invariably  in  the  posterior  quadrant,  and  irsually  in  the  postero-superior,  care 
must  be  taken  to  avoid  striking  the  long  portion  of  the  incus  with  the  point  of 
the  knife.  When  the  primary  incision  is  made  the  malleus  shaft  can  usually  be 
sufficiently  well  made  out  to  be  avoided;  but  if  the  knife  impinges  upon  this,  the 
operator  will  have  failed  to  secure  a  proper  opening,  the  resistance  being  firm  and 
the  knife  seldom  gliding  off  so  as  to  pass  through  the  membrane  and  evacuate  the 
contents  of  the  cavity.  To  avoid  injuring  the  incus  and  stapes  it  is  necessary  that 
the  operator  should  hold  the  instrument  delicately  between  the  thumb  and  finger 
in  making  the  upward  stroke,  when  contact  with  these  structures  will  be  imme- 
diately recognized,  and  the  blade  may  be  slightly  turned  so  as  to  avoid  them. 
Where  the  most  prominent  area  corresponds  to  the  lower  half  of  the  tympanic 
cavity  incision  in  the  opposite  direction  is  usually  more  convenient.  In  this  case 
the  Imife  is  introduced  in  the  canal  with  the  cutting  edge  downward.  Here  no  im- 
portant structures  can  be  encountered,  and  the  procedure  is  relatively  simple.  It 
is  usually  wise  to  make  this  incision  somewhat  curvilinear,  following  the  peripheral 
attachment  of  the  membrane,  the  incision  jDassing  close  to  the  cartilaginous  ring. 
Approximation  is  more  jjerfect  when  the  wound  is  located  here,  and  cicatrization 
correspondingly  more  rapid.  In  all  cases  attended  with  congestion  or  an  inflani- 
matory  process  the  inner  tympanic  wall   should  be  incised  at  the  same  time  to 


Pig.  366. — Method  of  incising  membrana 
tympani  to  e^^acuate  fluid  in  tlie  atriuna 
(natural  size). 


Fig.  367. — Incision  of  Shrapnell's  membrane  in  the 
early  stages  of  acute  purulent  otitis.  (The  con- 
tinuation of  the  incision  upon  the  superior  wall 
of  the  canal  is  indicated  by  the  dotted  line.) 


secure  local  depletion.  Eegarding  the  absolute  extent  of  the  incision,  it  is  seldom 
"wise  that  this  should  be  shorter  than  one  fourth  of  the  long  diameter  of  the 
membrane  if  lying  in  a  vertical  direction,  or  less  than  one  eighth  of  the  periphery 
if  located  near  this. 

"  It  is  well  to  remember  that  the  plane  of  the  memljrana  tympani  is  obliquely 
placed  to  both  the  horizontal  and  vertical  transverse  planes  of  the  body.  An  in- 
strument introduced  into  the  meatus  and  carried  horizontally  inward  will  fre- 
quently not  pass  through  the  drum  membrane,  but  will  l)e  deflected  from  its  surface 


290  THE   EAR 

and  inflict  but  a  superficial  wound.  This  is  particularly  true  when  the  bulging- 
involves  the  superior  segment,  and  in  children.  In  order  to  enter  the  tympanic 
cavity  the  knife  must  be  passed  not  only  inward,  but  inward  and  upward,  and 
even  after  the  point  has  passed  through  the  membrane  the  handle  should  be  strongly 
depressed,  so  as  to  carry  the  blade  well  up  into  the  cavity.  In  an  infant  the  plane 
of  the  membrane  is  nearly  horizontal,  and  unless  particular  attention  is  given  to 
this  fact  the  operation  will  be  inefficiently  performed.  It  is  well  in  operating  upon 
a  young  child,  and  even  upon  an  adult  where  the  canal  is  narrow,  to  employ  a 
curved  knife  rather  than  a  straight  one,  as  an  extensive  incision  is  more  easily 
made  if  this  is  done. 

"  Where  myringotomy  is  performed  for  depletion  alone  in  those  cases  where 
the  acute  inflammatory  process  has  begun  in  the  vault  of  the  tympanum,  the 
atrium  remaining  free,  success  in  aborting  the  attack  will  depend  largely  upon 
the  thoroughness  with  wliich  the  connective-tissue  structures  lying  in  the  tym- 
panic vault  are  divided.  In  such  a  case  the  knife  should  be  introduced  with  the 
blade  lying  in  the  horizontal  plane,  the  cutting  edge  looking  backward  (Fig.  367). 
The  point  punctures  the  dium  membrane  just  above  and  behind  the  short  process, 
of  the  malleus,  the  knife  being  passed  iTpward  and  inward  and  a  little  backward, 
to  avoid  the  body  of  the  incus.  The  incision  is  then  carried  horizontally  back- 
ward to  the  periphery,  when  the  cutting  edge  of  the  knife  is  turned  upward  and 
the  incision  extended  for  a  short  distance  along  the  superior  wall  of  the  canal 
(as  shown  by  the  dotted  line  in  Fig.  367).  This  severs  the  numeroiis  reduplica- 
tions of  mucous  membrane,  and  efficiently  depletes  this  region  and  the  lining 
membrane  of  the  mastoid  antrum."' 

Otitis  Media. — Infection  of  the  middle  ear,  by  reason  of  the  importance  of  the 
organ  involved,  the  complicated  and  delicate  mechanism  crowded  into  such  a 
limited  space,  and  its  location  practically  in  contact  with  the  brain,  is  fraught 
with  such  great  danger  "that  it  is  entitled  to  be  classed  with  the  most  important 
surgical  lesions.  The  route  of  infection  is  through  the  Eustachian  tube,  rarely 
through  the  drum,  less  rarely  through  the  blood.  It  may  be  said  that  the  failure 
to  take  reasonable  care  of  the  nasopharynx  and  tonsils  is  the  most  common  cause 
of  the  Eustachian  tube  inflammation  and  otitis.  The  prompt  removal  of  enlarged 
and  habitually  infected  tonsils,  of  adenoids  and  diseased  turbinated  tufts,  would 
mahe  impossible  a  large  piOj)ortion  of  these  distressing  infections.  Usually  follow- 
ing a  more  or  less  persistent  pharyngeal  inflammation,  otitis  media  is  ushered  in 
with  an  overwhelmingly  acute  pain,  with  high  fever,  deafness,  tinnitus,  and  with 
commencing  involvement  of  the  internal  ear,  nausea,  dizziness,  and  vomiting. 

Inspection  will  show  a  bulging  drum,  and  inflation  through  the  tube  will  give 
the  churiling  rales  of  thick  fluid  in  the  tympanic  cavity. 

In  order  to  forestall  mastoid  involvement,  incision  of  the  drum  is  imperative. 
With  everything  in  readiness,  nitrous-oxide  gas  is  administered. 

"  In  order  that  the  drainage  may  be  perfect,  the  lowest  point  of  the  opening 
must  lie  near  the  inferior  pole  of  the  drum  membrane.  Since  the  upper  and 
posterior  part  of  the  cavity  is  the  most  capacious,  an  effusion  sufficient  in  amount 
to  demand  evacuation  usually  causes  a  bulging  of  the  drum  membrane  in  this 
locality.  I  prefer,  therefore,  to  insert  an  exceedingly  sharp  but  delicate  knife  close 
to  the  periphery  of  the  membrana  at  a  point  opposite  the  short  process;  the  knife 
is  then  carried  downward  close  to  the  periphery  to  the  lowest  point  of  attachment 
of  the  membrana  tympani.  The  section  lies  entirely  within  the  clear  membrane, 
and  should  not  wound  the  cartilaginous  ring.  When  considerable  congestion  is 
present  it  is  advisable  to  secure  local  depletion  by  carrying  the  knife  sufficiently 
inward  to  make  it  impinge  upon  the  internal  tympanic  wall  so  as  to  divide  the 
soft  parts  which  cover  it,  throughout  the  entire  extent  of  the  incision  through  the 
drum  membrane.  If  the  parts  above  the  short  process  are  intensely  congested, 
the  incision  is  to  be  extended  upward  so  as  to  enter  the  vault  and  deplete  the 
engorged  tissues.  In  these  cases  it  is  usual  to  incise  from  below  upward  (Fig.  366). 
A  few  vigorous  efforts  at  inflation  by  means  of  the  Politzer  method  clears  the 
cavity  completely  of  fluid,  the  divided  parts  fall  readily  into  place,  approximation 
being  practically  perfect,   and   it  is  not  unusual  to  find  complete  union  at  the 


THE   EAR  291 

end  of  thirty-six  hours.  The  only  possible  nntoward  result  following  this  pro- 
cedure is  accidental  infection  at  the  time  of  the  operation.  To  avoid  this  the 
canal  should  be  first  syringed  with  a  solution  of  bichloride  of  mercury  (1-8000), 
while  the  instruments  employed  should  be  sterilized  by  boiling.  After  the  fluid  has 
been  evacuated  the  canal  should  be  closed  by  a  plug  of  aseptic  cotton  and  the 
patient  should  on  no  condition  interfere  with  it.  Carried  out  in  this  manner, 
there  is  absolutely  no  danger  in  adopting  this  method  of  treatment  for  an  effusion 
of  any  kind  within  the  tympanic  cavity.  AVhen  spontaneous  perforation  has  taken 
place,  it  is  usually  necessary  to  enlarge  the  opening.  This  measure  should  be 
carried  out  according  to  the  rule  which  governs  the  ^jrimar}'  incision. 

"  Upon  the  appearance  of  discharge  after  spontaneous  rupture,  or  after  surgical 
interference,  the  canal  must  be  kept  as  free  as  possible  by  frequent  irrigation  with 
a  warm  antiseptic  solution."     (Dench.) 

The  Mastoid  Cells. — With  the  first  symptoms  of  mastoid  inflammation,  incision 
and  drainage  of  these  cells  should  be  done.  If  the  operator  is  in  doubt  as  to  their 
involvement,  this  procedure  should  be  advised,  as  it  gives  an  assurance  of  safety. 

The  arrangement  of  the  mastoid  cells,  which  are  more  or  less  in  direct  com- 
munication with  the  middle  ear,  vary  at  different  periods  of  life  and  in  different 
individuals.  At  times  this  process  is  eburnated,  containing  practically  no  cavities; 
under  other  conditions  it  is  spongy  and  permeated  with  recesses. 

"  Owing  to  the  invariable  presence  of  the  mastoid  antrum,  its  location  is  a 
matter  of  importance.  It  is  best  located  by  bearing  in  mind  its  relation  to  the 
superior  and  posterior  walls  of  the  external  auditory  meatus.  If  two  lines  be 
drawn — one  horizontal,  tangent  to  the  superior  wall  of  the  external  auditory  canal, 
the  second  vertical  and  tangent  to  its  posterior  wall — the  point  of  their  intersection 
will  be  the  apex  of  a  triangle  the  base  of  which  will  be  formed  l^y  that  portion 
of  the  curvilinear  outline  of  the  meatus  included  between  the  points  of  tangency 
of  these  lines.  This  triangle  lies  immediately  over  the  antrum  and  an  artiflcial 
opening  within  this  space  will  enter  the  cavity."     (Dench.) 

In  infants  the  mastoid  is  poorly  developed,  consisting  usually  of  a  single  cell — 
the  antrum.  As  the  vault  of  the  tympanum  in  the  child  is  nearly  as  large  as  in  the 
adult,  it  may  be  opened  if  great  care  is  not  exercised.  Mastoid  infection  is  caused 
almost  always  from  the  extension  of  septic  process  involving  the  middle  ear.  It 
may  possibly  occur  as  a  direct  infection  through  the  blood.  If  not  evacuated  early, 
the  septic  material  may  find  its  way  through  the  roof  of  the  antrum,  or  tympanic 
cavity,  to  the  middle  cranial  fossa,  or  to  the  meninges  of  the  posterior  cerebro- 
cerebellar  fossae,  or  into  the  general  circulation  through  the  small  veins  and  the 
lateral  sinus.  The  symptoms  are  usually  intense  pain,  severe  at  night,  rendered 
more  acute  by  percussion  upon  the  mastoid.  It  has  almost  always  been  preceded 
by  Eustachian  tube  involvement.  Although  not  of  real  diagnostic  value,  the  tem- 
perature is  usually  elevated.  In  addition  to  the  local  tenderness,  there  is  often 
seen  a  depression,  or  sagging,  of  the  superior  posterior  wall  of  the  canal,  close 
to  the  tympanic, ring.  The  ophthalmoscope  should  be  used  in  the  early  recognition 
of  choked  optic  disk,  one  of  the  most  important  signs  of  cerebral  involvement. 

Tlie  Mastoid  Operation. — Although  a  septic  area  is  to  be  laid  open,  on  account 
of  the  immediate  proximity  of  the  meninges,  brain  and  lateral  sinus,  every  possible 
antiseptic  precaution  is  imperative.  Shave  in  every  direction  for  three  inches  from 
the  mastoid,  irrigate  the  meatus  with  1-1000  mercuric  chloride,  and  follow  with 
hot  salt  solution;  plug  the  meatus  with  sterile  gauze,  and  apply  moist  1-3000 
bichloride  dressing  until  the  patient  is  anaesthetized. 

Beginning  one  half  inch  below  the  tip  of  the  mastoid  process,  carry  an  incision 
upward  and  forward,  curving  it  to  run  about  an  eighth  of  an  inch  from  and 
parallel  witli  the  norinal  curve  of  the  auricular  crease,  so  that  the  resulting  scar 
may  be  concealed.  It  should  divide  everything,  including  the  periosteum,  which, 
when  elevated,  lifts  the  solid  flap.  Arrest  all  bleeding,  retract  the  auricle  forward, 
and  with  dull  half-curved  scissors  closely  clip  the  muscular  insertion  from  the 
tip  of  the  mastoid. 

The  antrum,  located  just  behind  the  posterior  margin  of  the  meatus  and  just 
below  its  upper  margin,  is  now  opened  by  light  strokes  on  a  small  curved  chisel. 


292  THE   EAR 

From  this  point  of  entrance  the  entire  septic  area  may  be  exposed.  The  cutting 
edge  of  the  chisel,  or  rongeur,  sliould  be  guarded  from  tlie  lateral  sinus,  the  jugular 
vein  or  the  facial  nerve.  Upon  opening  the  antrum  the  route  to  the  middle  ear 
is  determined  by  passing  a  small  probe,  slightly  bent  at  the  tip,  forward,  downward, 
and  inward  for  about  three  quarters  of  an  inch.  This  passage  into  the  tympanum 
is  curetted  with  a  small,  sharp  spoon,  and  the  spongy  tissue  of  the  mastoid  thor- 
oughly removed  with  the  rongeur  and  sharp  spoon. 

From  this  initial  incision  any  of  the  various  complications  may  be  dealt  with. 

Should  the  necrotic  process  have  involved  the  contiguous  skull  bone,  the  oper- 
ative field  may  be  enlarged  by  extending  the  horizontal  incision  backward  for  an 
inch  or  more  from  the  middle  of  the  primary  mastoid  incision.  In  lifting  the 
periosteum,  a  short  vein  leading  into  the  lateral  sinus  is  often  wounded,  and  may 
require  compression  or  a  temporary  plug  to  control  haemorrhage.  If  the  inner 
table  is  involved,  it  should  also  be  removed,  and  the  dura  carefull}^  examined  and 
incised,  if  there  are  symptoms  of  local  meningitis.  In  this  operation  the  lateral 
sinus  may  be  opened,  but  haemorrhage  from  this  source  may  be  readily  controlled 
by  packing.  Such  is  the  necessity  for  free  exposure  and  drainage  in  this  important 
operation,  that  opening  the  lateral  sinus  or  the  dura  is  of  small  consequence  when 
compared  with  the  dangers  from  imprisoned  septic  matter. 

In  the  after-treatment  it  is  exceedingly  important  to  take  every  precaution  to 
prevent  infection  of  the  sinus  or  dura.  The  facial  nerve  as  it  crosses  the  tympanic 
cavity  may  be  wounded,  esp)ecially  where  it  has  been  necessary  to  remove  the  bone 
to  a  sufficient  depth  to  expose  the  internal  wall  of  the  middle  ear  (Bench).  It  is 
therefore  important  to  bear  in  mind  the  relation  of  the  internal  wall  of  the  tym- 
panic cavity  over  which  the  aqussductus  Fallojiii  passes. 

The  relation  of  the  lateral  sinus  to  the  antrum  varies  in  different  individuals.  It 
is  usually  just  behind  the -antrum,  and  when  for  any  reason  it  is  necessary  to  expose 
it,  this  can  be  done  by  extending  the  opening  in  the  bone  backward,  care  being  taken 
to  avoid  the  removal  of  the  bone  beyond  the  occipito-temporal  suture.  The  groove 
lodging  the  knee  of  the  sinus  is  located  in  the  mastoid  process,  and  an  extension 
of  the  opening  to  the  occipito-temporal  suture  gives  abundant  room  for  examining 
the  sinus  and  the  posterior  fossa,  both  above  and  below  the  tentorium  cerebelli. 

Sinus  Thrombosis. — In  addition  to  pain  and  preexisting  otitis  or  mastoiditis, 
wide  fluctuations  in  temperature  is  considered  one  of  the  most  imjiortant  charac- 
teristic features  of  sinus  thrombosis.  As  the  disease  progresses,  the  symptoms  of 
general  sepsis  are  more  appreciable,  on  accomit  of  the  dislodgment  of  septic  par- 
ticles and  their  dispersion  by  the  jugular  vein  through  the  general  circulation. 
When  meningeal  symptoms  supervene,  the  temperature  is  remittent  rather  than 
intermittent,  and  as  the  thrombus  extends  down  the  jugular,  the  line  of  tenderness 
corresponds  to  the  location  of  this  vein.  Careful  watch  should  be  kept  upon  the 
retina,  since  the  recognition  of  a  choked  disk  goes  far  to  confirm  the  diagnosis  of 
sinus  thrombosis  in  doubtful  cases. 

Operation. — Expose  the  sinus  by  perforating  the  skull  at  a  point  approximately 
half  an  inch  behind  the  posterior  margin  of  the  external  auditory  meatus.  As 
soon  as  the  dura  is  exposed,  introduce  a  dull-pointed,  grooved  director,  and 
carefully  separate  the  dura  from  the  skull;  after  which  enlarge  the  opening 
upward  and  downward  with  a  rongeur.  Uncover  the  sinus  for  aljout  one  inch.  .In 
a  normal  sinus  distinct  pulsation  is  usually  felt.  If  the  blood  is  flowing  through, 
pressure  on  the  lower  portion  will  cause  a  slight  dilatation.  If  there  is  any  doubt 
in  the  mind  of  the  surgeon  as  to  the  presence  of  a  clot,  an  exploratory  incision 
should  be  made;  a  puncture  will  not  suffice.  Compress  the  vessel  above  and  open 
the  wall  of  the  vein  longitudinally  about  a  quarter  of  an  inch,  making  immediate 
compression  below  to  prevent  the  induction  of  air.  If  free  hfemorrhage  does  not 
occur,  occlusion  of  the  vessel  by  clot  is  evident.  The  incision  should  then  be  en- 
larged and  a  blimt  curette  introduced,  and  the  clot  carefully  but  thoroughly 
removed.  This  instrument  should  be  passed  well  downward  into  the  bulb  until 
bleeding  from  that  direction  takes  place.  This  may  be  controlled  bv  a  pledget  of 
gauze  packed  over  the  lower  portion  of  the  opening.  ,  The  curette  should"  then 
be  used  in  the  opposite  direction  toward  the  torcular,  and  the  clot  removed  in  this 


THE  EAR  293 

direction  until  free  lisemorrhage  results.  If  free  lisemorrhage  from  below  does  not 
occur,  it  indicates  that  the  internal  jugular  vein  is  occluded.  This  vein  should 
now  be  exposed  by  the  proper  incision  along  the  anterior  border  of  the  sterno- 
mastoid  muscle,  carefully  separating  it  from  the  pneumogastric  nerve  and  the 
common  carotid  artery. 

Below  the  limit  of  the  thrombus  two  ligatures  of  ISTo.  3  chromicized  catgut  are 
passed  around  the  vein  one  half  inch  apart,  and  the  vessel  divided  between  them. 
The  upper  diseased  portion  is  dissected  out,  tying  off  and  dividing  all  tributary 
branches  as  high  as  possible,  when  it  is  again  tied  about  one  inch  below  the  jugular 
fossa  and  divided.  No  irrigation  of  the  sinus  from  the  jugular  should  be  attempted. 
The  entire  wound  should  now  be  flushed  with  hot  salt  solution,  and  closed  by 
silkworm-gut  sutures,  with  catgut  bundle  drains,  as  indicated.  In  dressing  the 
mastoid  wound,  care  should  be  taken  to  separate  the  antrum  from  the  open  sinus 
by  a  carefully  inserted  gauze  packing. 

Infection,  following  mastoid  involvement  or  purulent  otitis  media,  may  cause 
extra-  or  intradural  abscess.  The  symptoms  of  extradural  abscess  are :  severe,  con- 
tinuous, localized  headache,  with  a  temperature  which,  as  a  rule,  does  not  rise 
above  101°  or  102°  F.,  and  which  while  undergoing  slight  iiuctuations  slowly 
drops  to  the  normal.  As  no  portion  of  the  motor  tract  is  involved,  there  are 
no  localizing  symptoms. 

In  arriving  at  a  diagnosis  of  cerebral  abscess  the  history  of  the  case  is  important. 
Where  chronic  otitis  has  existed,  or  where  several  acute  attacks  have  occurred,  if 
these  are  followed  by  persistent  sleeplessness  and  a  temperature  remaining  steadily 
at  alwut  99°  F.,  von  Bergmann  insists  that  these  are  sufficient  indications  for  open- 
ing the  cranial  cavity  for  the  purpose  of  exploration.  Dench  advises,  however,  to 
await  some  localizing  s3inptoms  or  some  more  pronounced  condition  of  hebetude. 
An  argument  in  favor  of  early  intervention  is  advanced  from  the  fact  that  cerebral 
abscess  is  usually  deeply  situated  and  is  apt  to  rupture  into  the  lateral  ventricle. 
Vomiting  is  more  persistently  a  sjTnptom  of  cerebellar  than  of  cerebral  involvement. 
The  patient  is  dull,  apathetic,  complains  at  times  of  severe  headache,  although  this 
is  not  always  a  prominent  S3'mptom. 

The  most  frequent  site  of  an  abscess  from  middle-ear  sup|)uration  is  the  temporo- 
splienoidal  lobe;  second  the  cerebellum. 

The  first  step  is  to  enter  the  mastoid  antrum  and  expose  the  roof  of  the  tym- 
panum and  the  antrum,  entering  the  cranial  cavity  just  above  the  external  auditory 
meatus,  where  the  skull  is  usuallj'  very  thin.  The  bone  should  be  eaten  away  with 
a  rongeur,  malving  an  opening  at  least  one  inch  in  diameter.  The  dura  should  be 
carefully  lifted  with  a  grooved  director  from  the  upper  surface  of  the  petrous  por- 
tion of  the  temporal  bone,  and  careful  exploration  made  with  the  finger.  If  no 
pus  is  discovered  the  opening  should  be  enlarged  downward  and  baclvward  by 
removing  the  floor  of  the  middle  fossa  sufficiently  to  expose  the  lower  surface  of 
the  temporo-sphenoidal  lobe.  A  U-shaped  incision  should  be  made  in  the  dura, 
and  the  flap  reflected  upward.  Exploration  of  the  brain  substance  may  now  be 
made,  preferablj''  with  a  small  grooved  director  in  the  hope  of  finding  the  abscess 
cavity.  The  use  of  a  knife  is  objectionable  on  account  of  danger  of  dividing  a 
blood  vessel.  If  the  grooved  director  reveals  notliing,  a  good-sized  aspirator  needle 
may 'be  employed.  When  pus  is  discovered  a  dull-pointed  dressing  forceps  should 
be  carried  into  the  abscess  and  free  drainage  secured  through  the  opening  in  the 
dura  and  skull.  Irrigation  is  not  advised.  Ten-day  catgut  bundle  drainage  on  a 
film  of  gauze  may  .be  used.  A  loose  dressing  of  sterile  gauze  should  be  applied, 
and  this  should  be  changed  only  for  purposes  of  cleansing  or  a  threatening  eleva- 
tion of  temperature  or  other  urgent  reason. 

In  suspected  cerebellar  abscess,  the  point  of  election  for  an  exploratory  opening 
is  one  and  one  half  inches  Ijehind  the  center  of  the  external  auditory  meatus,  and 
one  fourth  inch  below  the  horizontal  plane  passing  through  the  center  of  the  ex- 
ternal auditory  canal.  After  the  periosteum  is  raised  the  bone,  which  is  quite 
thin  here,  may  be  readily  opened  by  a  few  strokes  of  the  chisel,  which  should  be 
enlarged  by  means  of  the  rongeur  forceps.  A  dural  flap  should  be  made  and 
exploration  done  as  in  the  preceding  operation. 


CHAPTER    XIV 

TITE    NOSE 

Fractures  of  the  bones  and  cartilages  of  the  nose  have  already  been  considered. 

Epistaxis,  or  hseniorrhage  from  the  nose,  may  be  arrested  by  spraying  tlie 
bleeding  meatus  with  a  small  quantity  of  a  five-per-cent  cocaine  sohition,  followed 
by  adrenalin  solution  (1-1000)  in  normal  saline.  One  or  both  of  these  local 
applications  cause  the  mucous  membrane  to  shrink.  If  not  arrested  the  bleeding 
point  may  now  be  recognized  with  the  aid  of  the  speculum  and  reflected  light,  and 
a  concentrated  astringent  ajjplied,  such  as  powdered  alum,  on  a  pledget  of  sterile 
gauze  or  cotton.  Plugging  or  tamponing  the  nares  will  only  be  necessary  in  extreme 
cases.    The  technic  is  as  follows: 

First,  determine  accurately  the  nostril  in  which  the  bleeding  is  occurring.  Take 
a  piece  of  fine  sponge  at  least  an  inch  in  diameter  when  dry  (and  it  should  be 
introduced  without  being  moistened,  so  that  when  in  position  in  the  posterior  nares 
it  will  expand  as  the  blood  moistens  it),  and  tie  around  its  center  three  strong  silk 
threads.  A  soft  catheter  or  bougie  is  now  introduced  into  the  nostril  from  the 
front,  keeping  the  point -of  the  instrument  well  on  the  floor  of  the  nose.  As  soon 
as  the  end  is  seen  or  felt  behind  the  soft  palate,  it  is  dra'\\Ta  out  of  the  mouth 
by  the  forceps  or  fingers.  Two  of  the  tlii'ee  threads  are  attached  to  the  point  of 
the  instrument,  which  is  then  pulled  back  through  the  nostril.  When  the  threads 
come  out  of  the  nose  in  front  the}^  are  seized  by  the  fingers  of  one  hand  while  the 
sponge  is  carefully  guided  into  position  hehind  the  soft  palate  with  the  other. 
Once  well  in  the  posterior  nares  it  is  held  in  position  and  made  to  exert  the  neces- 
sary compression  by  tying  the  two  anterior  strings  over  a  softened  sponge  packed 
into  the  nostril  in  front.  The  third  thread  is  brought  out  of  the  mouth,  and  is 
to  be  used  in  dislodging  the  tampon  when  the  hajmorrhage  has  ceased.  Lint,  soft 
rags,  or  cotton  may  be  used  for  plugs  when  a  sponge  cannot  be  obtained.  A  long 
probe  or  a  loop  of  soft  wire  may  be  used  instead  of  the  bougie. 

In  this,  as  in  all  other  internal  haemorrhages,  the  arrest  of  bleeding  is  facilitated 
by  ligation  of  the  extremities.  This  consists  in  applying  an  elastic  bandage  (or 
an  ordinary  roller,  if  tlie  rubber  cannot  be  obtained)  around  the  thighs  and  arms 
close  to  the  trunk,  and  making  the  jjressure  strong  enough  to  arrest,  in  great  part, 
the  return  of  blood  through  the  veins  without  arresting  the  circulation  in  the 
arteries.  When  the  haemorrhage  ceases  the  ligatures  should  be  .gradually  loosened,' 
so  that  the  volume  of  blood  which  has  been  confined  in  the  extremities  may  not 
be  too  suddenly  returned  to  the  heart. 

Foreign  Bodies. — Buttons,  seeds,  and  other  substances  are  often  lodged  in  the 
cavity  of  the  nose.  The  usual  seat  of  lodgment  is  in  the  anterior  part  of  the 
inferior  meatus,  or  between  the  lower  turbinated  bone  and  the  septum,  and  occa- 
sionally they  are  pushed  beyond  this  into  the  middle  meatus. 

Any  foreign  body  should  be  removed  at  once,  as  it  is  not  only  painful,  but 
tends  to  produce  inflammation  of  the  lining  membrane  and  not  infrequently  os- 
titis. Its  presence  may  be  indicated  by  a  change  of  the  voice  from  its  natural 
to  a  nasal  tone.  If  the  mucous  membrane  is  swollen,  spraying  with  weak  cocaine 
and  adrenalin  solutions,  aided  by  the  speculum  and  reflected  light,  will  enable 
the  surgeon  to  locate  it.  Strong  slender  forceps  bent  at  an  angle  so  that  the  hand 
of  the  operator  will  not  shut  out  the  light,  is  the  most  suitable  instrument  to  be 
employed  in  extraction.  Should  the  body  be  lodged  well  back,  it  may  be  pushed 
into  the  nasopharynx,  to  be  ejected  through  the  mouth. 

294 


THE   NOSE 


295 


9 


s 


RMnolites,  or  nasal  calculi,  are  occasionallj'  seen,  and  probably  originate  in 
the  lachrynial  apparatus.  Laclirj-nial  concretions  (dachryolites)  sometimes  plug 
the  tear  passages.  These  bodies  should  he  removed  with  forceps  as  soon  as  dis- 
covered. 

Neoplasms. — The  most  frequent  variety  of  tumor  within  the  nasal  cavity  is  the 
myxoma,  or  so-called  gelatinous  polypus.  ISText  in  order  of  frequency  is  the  fibroma 
or  fibrous  polypus.  Both  of  these  belong  microscopically  to  the  connective-tissue 
tumors,  the  m'yxomata  being  allied  to  the  embryonic,  the  fibromata 
to  the  more  developed  connective-tissue  tumors.  PapiUomata,  or 
warts,  are  not  infrequently  seen  at  the  edges  of  the  mucous  mem- 
brane of  the  nostrils.  Lastly,  there  may  he  a  general  hypertrophy 
of  the  mucous  membrane  of  the  nose,  causing  a  tumefaction  of 
the  turbinated  tufts,  and  |)artial,  or  may  be  complete,  occlusion  of 
the  nares. 

Gelatinous  nasal  polypi  are  usually  pear-shaped,  the  bulk  of 
the  tumor  tending  toward  the  floor  of  the  nose.  The  pedicle  is 
attached  to  one  of  the  thick  velvety  tufts,  most  frequently  in  the 
upper  or  middle  meatus.  There  may  be  a  single  tumor,  although 
the  rule  is  for  them  to  be  multiple.  They  are  of  light-gra3-ish 
color,  and  are  colored  by  mucous  exudation. 

The  symptoms  are  chiefly  those  due  to  pressure  and  obstruction 
of  the  nares.  Changes  in  the  voice  are  not  marked  until  the  pres- 
ence of  the  tumor  has  l^een  suspected  from  pressure  and  irritation. 
This  irritation  gives  rise  to  an  excessive  secretion  and  discharge 
from  the  nose,  and  occasionally  to  prolonged  and  violent  fits  of 
sneezing. 

The  diagnosis  may  be  rendered  positive  by  physical  exploration. 
The  shrinkage  of  the  turbinated  tufts,  following  the  local  use  of 
cocaine  hydrochlorate,  renders  inspection  more  easy. 

Treatment. — The  only  rational  method  of  treatment  is  removal 
and  destruction  of  the  pedicle  and  contiguous  mucous  membrane. 
Avulsion  may  be  effected  by  seizing  the  growth  with  a  long,  deli- 
cate polypus  forceps,  and  twisting  the  tumor  around  until  the 
pedicle  is  wrung  ofl;,  then  applying  pure  nitric  acid  or  the  galvano- 
cautery  to  the  stump.  The  wire  ecraseur  or  snare  of  Jarvis  is 
greatly  to  be  preferred  (Fig.  369).  After  the  wire  loop  has  been 
passed  around  the  tumor,  and  slipped  up  to  the  pedicle,  it  should 
be  slowly  tightened,  since  by  this  method  the  danger  of  lijemor- 
rhage  which  alwaj's  follows  the  use  of  the  forceps  is  avoided. 
From  one  to  two  hours  may  be  consumed  in  the  division  of  the 
growth,  the  screw  being  turned  from  time  to  time.  Nitric  acid 
or  the  cauterj'  should  be  applied  to  the  stump  in  all  cases,  since 
without  this  recurrence  is  almost  certain. 

Fibromata,  or  fibrous  polypi,  are  much  less  frequent  than  the 
myxomata.  As  a  rule  they  are  deeper  situated.  They  require 
the  same  treatment  as  above  given.  Occasionally  large  tumors 
of  the  nasal  cavities  require  for  their  complete  removal  section  of 
the  nasal  and  superior  maxillary  bones. 

PapiUomata,  or  warts,  which  occur  at  the  junction  of  the  mu- 
cous membrane  of  the  nares  with  the  integument,  should  be  clipped 
off  with,  curved  scissors  and  their  bases  burned  with  pure  nitric 
acid. 

Fissures  of  the  nares  may  be  relieved  by  the  repeated  local  use 
of  the  lunar-caustic  pencil.  The  application  of  cold  cream  at  bed- 
time will  aid  in  preventing  a  recurrence. 

Ozaina. — Oztena  is  the  name  given  to  a  chronic  inflammation  of  one  or  more 
of  the  nasal  cavities,  or  the  sinuses  communicating  with  them.  It  may  be  con- 
fined to  a  process  of  ulceration  of  the  soft  tissues  alone,  but  the  bone  is  usually 
involved.     Syphilitic  ozsena  is  probably  the  most   common  form.     It  frequently 


Fig.  369.— Jarvis' 

snare. 


296 


THE  NOSE 


occurs  with  other  d3^scrasife.  It  is  accompanied  by  a  foetid  odor  and  a  muco- 
purulent discharge,  partially  liquid  and  partially  solid.  Atrophy,  or  destruction 
of  the  turbinated  tufts,  is  not  infrequent,  so  that  there  is  abnormal  space  withiu 
the  nares. 

The  treatment  is  local  and  general.  The  removal  of  diseased  or  dead  bone  is 
imperative,  and  irrigation  with  the  weaker  sublimate  solutions  should  be  regularly 
made. 

Dobell's  solution  will  be  found  of  use:  Carbolic  acid,  gr.  x;  biborate  and  bicar- 
bonate of  soda,  each,  3  j ;  glycerine,  ox ;  to  this  add  water  to  make  gx.  This  should 
be  used  five  or  six  times  a  day  as  a  douche.  The  general  condition  of  the  jDatient 
should  be  imjaroved  by  the  administration  of  well-selected  tonics  and  food,  and  by 
out-of-door  life. 

Superficial  epithelioma,  situated  upon  the  nose  or  face,  should  be  destroyed  by 
the  application  of  Marsden's  paste.  If  the  first  application  is  not  sufficient,  it 
should  be  repeated  in  three  weeks. 

Hypertrophic  rhinitis  consists  in  a  general  connective-tissue  hyjDertrophy  of  the 
lining  membrane  of  the  nose,  with  relative  increase  in  the  number  and  size  of  the 
blood  vessels.  It  almost  invariably  coexists  with  deviation  of  the  septum,  and 
is  most  marked  on  the  side  least  obstructed.  In  order  to  determine  the  degree 
of  hypertrophy,  the  preliminary  examination  should  be  made  without  the  use  of 
cocaine  or  adrenalin,  since  these  cause  shrinlvage  and  disguise  the  condition  of 
turgescence. 

The  first  essential  in  treatment  is  the  correction  of  the  deflected  septum.  Any 
marked  angular  projection  may  be  removed  under  the  anesthesia  of  cocaine,  applied 
at  first  by  a  spray,  followed  by  direct  local  application  with  a  pellet  of  cotton 
moistened  in  a  ten-p)er-cent  solution,  and  the  additional  submucous  infiltration  of 
a  weak  solution  by  means  of  a  hypodermic  needle.  If  only  a  small  projection  is 
to  be  removed,  the  mucous  membrane  may  be  sawed  through  with  the  laone,  but 
when  any  extensive  operation  is  to  be  performed  the  mucous  covering  should  be 
incised  and  lifted  to  be  replaced  after  the  deformed  bone  has  been  removed. 

This  minor  jjrocedure  may  not  alwaj^s  suffice,  and  for  the  more  extensive  opera- 
tion for  the  correction  of  a  badly  deflected  septum  the  method  of  Prof.  Jolm  B. 
Eoberts  is  recommended. 

Make  a  long  incision  at  the  most  prominent  portion  of  the  deviation,  and  sup- 
plement this  by  chopping  the  septum  full  of  incisions  with  the  stellate  punch. 
If  there  is  an  angular  deviation  close  to 
the  palatal  process  of  the  superior  maxil- 
lary bone,  make  an  incision  from  front 
to  back  at  the  most  prominent  part,  and 
do  not  chop)  the  upper  portion  with  the 
punch.  If  the  deviation  is  a  curved  one, 
split  the  cartilage  along  the  most  prom- 
inent portion  and  then  chop  the  rest  of 
the  septum  until  it  has  lost  its  resili- 


FiG.  370. — Roberts'  nasal  pin. 


Fig.  371. — Roberts'  method  of  holding  the  sep- 
tum in  correct  position  by  means  of  pins. 
Tlie  upper  part  of  the  septum,  immediately 
above  the  oblique  incision,  projected  too  far 
this  way  (i.  e.,  toward  the  reader).  It  is  now 
pressed  the  other  way  (i.e.,  from  the  reader) 
and  is  held  there  by  the  pins,  a,  Incision 
through  the  septum,     h,  c.  Pins  in  position. 


ency.      Afterward    cut    away    with    the 

chisel  or  saw  any  horizontal  bony  edge 

that  may  remain  at  the  bottom.    If  some 

small  triangular  pieces  are  removed  by 

the  interlacing  of  the  incisions  made  witli 

the  forceps,  it  makes  no  difEerence,  since  the  openings  left  are  very  small  and  will 

soon  become  closed.    To  hold  the  seijtum  in  place,  use  steel  pins  (Fig.  370),  either 

those  with  spherical  heads  of  glass,  or  the  flat-headed  pins.     When  the  head  of  the 

pin  is  to  be  within  the  nostril,  those  with  the  glass  heads  are  better ;  when  the  head 

is  to  lie  against -the  exterior  of  the  note,  the  flat  heads  are  preferable. 


THE   XOSE  297 

After  having  divided,  the  septiim  (a.  Fig.  371),  as  above  described,  introduce 
a  pin  (&)  into  the  more  open  nostril  and  thrust  its  poiat  through  the  anterior 
part  of  that  portion  of  the  divided  septum.  Displace  this  part  into  the  desired 
position,  thrust  the  point  of  the  pin  onward  and  bury  its  point  deep  in  the  tissues 
at  the  back  part  of  the  nasal  chamber  which  was  formerly  occluded.  This  holds 
the  septum  firmly  in  its  new  location.  The  head  of  this  pin  will  be  just  inside  of 
the  anterior  naris  which  was  not  obstructed,  and  will  lie  against  the  columella. 
It  should  be  allowed  to  remain  about  one  week,  for  if  left  a  longer  time  its  head 
will  probably  cause  ulceration  from  jjressure,  and  may  become  deeply  buried  in 
the  tissues.  It  is  often  well  to  introduce  a  second  pin  (c.  Fig.  371),  from  the 
external  surface  of  the  front  of  the  nose  Just  below  the  nasal  bones,  which  aids  in 
keeping  the  septal  cartilage  pinned  into  proper  jslace.  If  this  pin  has  a  fl.at  head, 
it  may  be  covered  with  a  small  square  of  court-plaster. 

In  many  instances  h}-pertrophy  of  the  turbinated  bones,  or  permanent  thicken- 
ing of  the  vascular  membrane  covering  them,  obstructs  the  nose  to  such  an  eitent 
that  the  passage  of  air  by  these  channels  is  diiScult  or  impossible,  or  deviation  of 
the  septimi  may  result.  Under  such  conditions,  removal  of  the  turbinated  bones 
and  tufts  is  indicated.  Eemoval  of  the  inferior  bone  and  tuft  will  usually  suiBce. 
The  inferior  tuft  is  commonly  implicated.  A  sufiBcient  degree  of  anaesthesia  may  be 
obtained  by  the  use  of  cocaine  hydi'ochlorate  as  above  directed.  The  turbinated  process 
should  be  divided  with  the  delicate  saw  close  to  its  attachment  to  the  superior  max- 
iUa.    Should  haemorrhage  be  troublesome,  it  may  be  arrested  by  plugging  the  nostril. 

When  the  bone  is  not  involved  in  the  hypertrophy,  the  thickened  mucous  mem- 
brane may  be  sufficiently  destroyed  by  means  of  the  galvano-cautery  or  by  the  re- 
peated application  of  chromic  acid.  Before  applving  the  acid  care  should  be  taken 
to  dry  the  nasal  mucous  membrane  with  a  pledget  of  cotton.  The  membrane  should 
first  be  exsanguinated  with  cocaine  spray,  and  then  a  small  bit  of  chromic  acid 
melted  upon  the  tip  of  a  metal  probe  should  be  applied  over  an  area  of  about 
one  fourth  of  an  inch  in  diameter. 

Any  excess  is  to  be  inxniediately  removed  by  means  of  a  dry  pledget  of  cotton. 
"  The  slough  separates  at  the  end  of  from  five  to  ten  days,  after  wliich  the  operation 
is  repeated  over  another  portion  of  the  turbinated  body.  These  applications  are 
continued  until  the  patency  of  the  passage  has  been  restored.  When  the  h^'per- 
trophy  is  excessive  the  cold  wire  snare  may  be  used  to  remove  redundant  portions. 
The  membrane  is  first  anesthetized  with  cocaine  and  the  loop  made  to  surround 
the  mass.  The  wire  is  then  drawn  into  the  tube  and  cuts  through  the  tissue  which 
it  surrounds.  When  the  mass  is  situated  in  the  posterior  nares  the  vrire  loop  should 
be  made  to  cut  tlirough  slowly  by  using  the  screw.  In  this  manner  hemorrhage  is 
avoided.  As  cocaine  exsanguinates  the  membrane,  it  is  weU  to  use  only  a  sufficient 
quantity  to  produce  anesthesia,  in  order  that  the  snare  may  remove  as  much  of 
the  swollen  mucous  membrane  as  possible.  After  the  operation  is  completed  a  little 
iodol  is  to  be  insuiBated  upon  the  cut  surface,  and  the  patient  directed  to  avoid 
forcible  efforts  at  clearing  the  nostril  for  at  least  twelve  hours.  In  this  way  hemor- 
rhage is  avoided,  and  prompt  recovery  is  the  rule.'"'     (Dench.) 

Atrophic  Ehinitis. — In  this  condition  the  nasal  cavities  are  covered  with  crusts, 
which  often  render  the  breath  extremely  offensive.  Although  frequently  incurable, 
this  distressing  condition  may  be  ameliorated  by  using  two  or  three  times  daily 
a  nasal  douche  composed  of  a  quart  of  weak  saline  solution  as  hot  as  can  be  borne. 
This  not  only  washes  away  decomposing  crusts,  but  exercises  a  certain  stimulating 
action  upon  the  membranes.  During  the  day  the  nasal  chambers  may  be  cleansed 
at  frequent  intervals  with  an  alkaline  spray,  composed  of 

^   Sod.  bicarb gr.  xx; 

Acid,   boric .5ss. ; 

Acid,  carbolic    TTliv ; 

Glycerin    .3 j ; 

Aqua q.   s.  ad  5vii]". 

M.  Sig. :  Dilute  with  an  equal  vohmie  of  water,  and  use  in  an  atomizer  as  a 
nasal  spray. 


298  THE   NOSE 

Later,  irrigation  ma)^  be  employed  but  once  daily.  If  faithfully  continued,  this 
treatment  will  prevent  the  discomfort  attendant  upon  the  nasal  affection.  The  use 
of  the  nasal  douche  in  these  cases  seldom  produces  aural  symptoms,  as  the  nasal 
passages  are  free  and  there  is  but  little  danger  of  the  fluid  entering  the  tympanum. 
It  should  always  be  remembered  in  employing  the  douche  that  the  current  should 
enter  by  the  occluded  nostril  if  there  is  any  difference  in  the  patency  of  the  two 
sides.     (Dencli.) 

Adenoid  Vegetations. — In  addition  to  the  neoplasms  and  hypertrophies  which 
interfere  with  the  respiratory  functions  of  the  anterior  nasal  cavity,  the  presence 
of  vegetations  located  chiefly  in  the  vault  of  nasopharynx  are  deserving  of  seri- 
ous surgical  consideration.  They  are  very  common  in  children,  especially  in  those 
living  in  cold,  damp  climates,  and  in  unhygienic  surroundings.  These  new  growths 
and  liypertrophies  not  only  prevent  natural  breathing  through  the  nose,  but  they 
lead  to  constant  infectious  processes  which  involve  almost  inevitably  the  Eu- 
stachian tube,  induce  otitis,  and  are  responsible  in  large  measure  for  the  serious 
disasters  not  only  to  the  functions  of  the  ear,  but  the  greater  dangers  which  follow 
purulent  otitis.  For  the  welfare  of  a  child  it  is  imperative  that  these  growths  be 
removed  as  soon  as  discovered. 

In  ordinary  cases  the  operation  can  be  readily  done  under  nitrous-oxide  gas 
auEesthesia,  the  whole  procedure  not  lasting  over  two  minutes.  When  by  reason 
of  neglect  a  more  formidable  operation  is  necessary,  ether  anaesthesia  is  preferable, 
and  since  adenoids  of  the  nasopharynx  are  almost  always  accompanied  by  enlarge- 
ment of  the  tonsils,  these  should  be  clipped  with  the  tonsilotome  just  jjefore  the 
removal  of  the  adenoids. 

^  The  head  of  the  patient  should  be  thro^i'n  backward  over  the  edge  of  the  table 
or  over  a  pillow,  in  this  position  making  the  vaiilt  of  the  pharynx  occupy  a  lower 
level  than  the  larynx,  reducing  to  a  minimiam  the  danger  of  the  accidental  intro- 
duction of  blood  into  the  trachea. 

"  The  jaws  are  held  apart  by  a  jDroperly  constructed  mouth-gag,  and  the  sur- 
geon, standing  upon  the  right  of  the  patient,  introduces  the  left  forefinger  behind 
the  palate,  where  it  remains  until  the  operation  is  completed.  The  closed  forceps 
held  in  tlie  right  hand  is  now  passed  along  the  left  forefinger  as  a  guide  into  the 
nasopliarynx,  where  it  is  opened  and  made  to  grasj)  as  much  of  the  growth  as 
possible,  the  manipulation  being  directed  by  tlie  left  index-finger.  In  this  way  the 
growth  is  removed  piecemeal,  and  tlie  operation  is  not  considered  complete  until 
the  examining  finger  fails  to  discover  any  masses  projecting  into  the  nasopharyn- 
geal space.  The  operation  is  completed  by  passing  the  curette  into  the  space  and 
sweeping  it  along  each  lateral  wall  and  along  the  posterior  wall  of  the  cavity.  The 
child  is  then  turned  over  on  the  face  to  facilitate  the  discharge  of  blood  whicli  has 
accumulated  in  the  nasopharynx  during  the  progress  of  the  operation,  the  mouth- 
gag  not  being  removed  until  this  position  lias  been  assumed.  No  after-treatment  is 
necessary."     (E.  B.  Bench.) 

Nasopharyngeal  Catarrli. — A  prominent  symptom  of  this  distressing  condition 
is  a  viscid  secretion  from  tlie  pharyngeal  vault  which  is  drawn  back  into  the 
mouth  for  exjDulsion.  It  is  another  common  source  of  infection  of  tlie  Eustachian 
tube. 

The  treatment  consists  in  the  local  application  to  the  pharyngeal  mucous  sur- 
faces of  a  solution  of  nitrate  of  silver,  applied  by  means  of  a  cotton-tipped  probe 
introduced  through  the  anterior  nares,  this  passage  having  been  previously  anass- 
thetized  with  cocaine.  The  strength  should  vary  with  the  intensity  of  the  in- 
flammation. In  the  early  or  most  acute  stage  a  solution  of  thirty  grains  to  the 
ounce,  thoroughly  applied,  may  arrest  the  disease.  In  the  later  stages  a  weaker 
solution  should  be  employed.      (Bench.) 

Angular  depressions,  caused  by  fracture  of  the  cartilage  or  bones  of  the  nose, 
may  be  remedied  by  lifting  the  skin  by  careful  subcutaneous  dissection  to  about  its 
normal  position,  and  holding  it  by  inserting  beneath  it  a  thin  plate  of  platinum. 

Under  careful  asepsis  an  incision  is  made,  splitting  the  skin  near  the  muco- 
cutaneous junction  of  the  nostril  on  either  side  as  far  as  the  middle  line  of  the 
tip  of  the  nose  with  a  delicate,  long,  narrow-bladed  knife.     The  dissection  is  con- 


THE  NOSE 


299 


tinned  npwarcl  between  the  cartilage  and  bones  of  the  nose,  and  the  integnment, 
until  the  whole  cutaneous  covering  of  the  nose  is  loosened  and  freely  movable  as 
far  as  the  level  of  the  lower  eyelid.  Bleeding  will  soon  cease  under  direct  j^ressure. 
A  piece  of  thin  platinum  cut  in  diamond  shape  and  bent  along  the  middle  line  at 
an  angle  something  like  the  roof  of  a  house,  carefully  sterilized  and  held  by  a 
delicate  narrow  forceps,  is  pushed  upward  from  the  suj)erficial  incision  until  it 
rests  over  the  depression  in  the  cartilage  or  bone.  Upon  this  the  skin  rests,  and 
the  depression  is  no  longer  perceptible.  The  incision  is  closed  by  a  few  interrupted 
horsehair  sutures   (Fig.  372).     The  subcutaneous  injections  of  paraffin  have  been 


Fig.  372. — Subcutaneous  platinum  support  restoring  the  normal  outline  of  the  nose. 


employed  successfully  by  Drs.  W.  H.  Luckett  and  F.  I.  Horn,  but  the  method  is 
still  in  the  exijerimeutal  stage.  Moreover,  several  serious  accidents  are  reported  as 
a  result  of  the  injections. 

Loss  of  substance  may  occur  from  the  accidental  or  siTrgical  ablation  of  all  or  a 
25ortion  of  this  organ,  or  from  its  destruction  by  disease.  The  diseases  which  most 
frequently  produce  loss  of  substance  are  syphilis,  lupus,  and  epithelioma.  Sarcoma, 
elepliantiasis,  or  any  neoplasm  may  involve  the  nose  and  cause  loss  of  tissue  in  its 
removal.  One  of  the  most  distressing  lesions  in  neglected  cases  of  (tertiary)  syph- 
ilis is  necrosis  of  the  cartilages  and  bones  of  the  nose,  resulting  in  great  disfigure- 
ment. Occasionally  sloughing  occurs,  from  the  presence  of  a  j)hagedenic  syphilide 
diu'ing  the  second  stage  of  this  disease. 

Rhinoplasty  may  be  j^artial  or  complete.  Complete  rhinoplasty  is  performed 
when  the  skin,  cartilages,  and  bones  of  the  nose  have  been  carried  away.  In  such 
cases  nothing  remains  but  an  irregular  sunken  pit,  leading  almost  directly  into  the 
pharynx. 

The  successful  and  satisfactory  restoration  of  this  organ  is  rarely  accomplished. 
It  would  be  well,  in  all  cases  of  complete  loss  of  the  nose,  to  consider  some  form 
of  prothetic  apparatus  before  resorting  to  a  plastic  operation. 

The  operation  consists  (1)  in  paring  the  margins  of  the  opening  and  the  in- 
tegument immediateh'  around  the  oiseuing,  in  apposition  to  \i'hich  the  transplanted 


300 


THE  NOSE 


flap  is  to  be  brought;  (2)  in  the  transportation  of  a  properly  shaped  piece  of  skin, 
with  its  underlying  tissues,  from  its  normal  to  the  new  position. 

The  flap  may  be  taken  entirely  from  the  forehead,  or  one  half  from  each  cheek, 
or  from  the  arm.  One  of  the  most  frequent  causes  of  failure  in  this  operation  is 
the  caving-in  of  the  ridge  of  the  new  nose,  and,  in  order  to  better  prevent  this,  tlie 
platinum  support  to  be  described  may  be  employed. 

Complete  Rhinoplasty  from  the  Forehead. — Cut  a  piece  of  chamois-skin,  or 
soft,  thin  leather,  of  the  shape  represented  in  Fig.  373.  Adjust  this  to  the  line 
of  the  nasal  cavity  to  see  if  it  is  large  enough  and  of  proper  shape.  Bear  in  mind 
the  following  points:  1.  The  flap  once  dissected  up  tends  to  contract.  It  should 
therefore  1)6  considerably  larger  than  a  pattern  which  fits  exactly.  8.  The  isthmus 
{d,  Pig.  373)  must  not  be  too  narrow,  for  fear  that  the  vitality  of  the  flap  may 
be  insufficient.  It  should  always  be  cut  so  as  to  include  the  angular  artery,  and 
should  be  broader  than  represented  in  the  accompanying  cut.  It  should  take  in  a 
portion  of  the  hair-covered  eyebrow,  since  this  insures  a  widtli  of  pedicle  suflicient 
to  nourish  the  flap,  and  the  hairy  stump,  when  turned  back  after  the  circulation 
is  established,  restores  the  normal  brow.  3.  The  distance  from  the  istlunus  {d) 
to  e',  where  the  lower  edge  of  the  new  nose  is  to  be,  should  be  considerably  less 
than  the  distance  from  d  io  a  c,  in  order  to  prevent  tension  of  the  flap  and  inter- 
ference with  the  circulation  through  the  pedicle,  d.    Lay  the  pattern  on  the  fore- 


FiG.   373. — (After  Linhart.) 


Fig.  374. — (After  Malgaigne.) 


head  and  outline  the  flap  by  making  punctures  at  intervals  of  every  fourth  "of  an 
inch  along  its  edges.  The  incision,  made  through  the  tissues  and  periosteum, 
should  begin  at  d  and  be  carried  to  a  c  c  a,  and  then  down  to  a  point  in  the  eyebrow 
farther  oiitward  than  represented  by  the  dark  line  at  d.  The  smaller  incisions  in 
the  flap  a  b  or  c  b  are  made  to  provide  for  the  septum  and  alfe  of  the  new  nose, 
when  the  platinum,  support  is  not  to  be  used.  The  flap  is  now  dissected  up  witli 
the  periosteum  as  far  as  the  pedicle,  when  it  is  turned  down  and  sewed  into  jDOsition 
with  fine  silk  sutures.  The  operation  is  completed  when  the  entire  flap  has  been 
accurately  stitched  to  the  freshened  edges  of  the  cavity,  as  shown  in  Fig.  374. 
Pieces  of  rubber  tubing  may  be  inserted  in  the  nostrils  to  hold  the  alffi  in  position, 
or  a  I3lug  of  sterile  gauze  not  too  tightly  packed  in  may  be  substituted.  It  should 
be  changed  as  often  as  it  becomes  moistened.  The  upper  part  of  the  wound  on 
the  forehead  is  dra^vn  as  near  together  as  can  be  done,  with  silkworm-gut  sutures, 
and  an  iodoform-gauze  dressing  is  applied.     No  pressure  must  be  exercised  upon 


THE   NOSE  301 

the  pedicle,  or  flap,  which  should  be  loosely  enveloped  in  the  dressing.  In  about 
two  weeks  the  circulation  will  have  been  sufficiently  established  between  the  flap 
and  the  edges  of  the  cavity  to  permit  the  section  of  the  j)ediele,  the  stump  of 
which  is  used  in  filling  up  the  gap  upon  tlie  forehead.  In  returning  the  jjediele  to 
its  original  position,  it  is  advisable  to  dissect  out  the  granulation  tissue  in  the 
wound,  so  that  the  returned  portion  will  sink  to  the  jDroper  level.  The  exposed 
surface  which  remains  u23on  the  forehead  should  be  covered  in  by  grafting  after 
the  methods  already  given. 

Partial  Rhinoplasty. — When  there  is  a  limited  loss  of  substance  confined  to  the 
ala,  the  cicatricial  edges  of  the  wing  of  the  defective  nostril  should  be  trimmed 
and  a  small  flap  turned  from  the  contigaious  integument  of  the  upper  lip  and  cheek. 

The  pedicle  should  be  left  wide  enough  to  insure  nutrition,  and  the  flap  should 
be  carefully  patterned  before  any  incision  is  made.  The  farthermost  portion  of 
the  wound  from  which  the  flap  has  been  removed  should  be  closed  at  once  with 
linen  or  horsehair  sutures,  while  the  nearer  jjortion  should  be  left  open.  In  about 
ten  days  the  jaedicle  may  be  divided  and  the  stump  reimbedded  in  the  remaining 
open  23ortion  of  the  wound. 

Should  the  integument  and  cartilage  along  the  middle  line  be  destroyed,  leaving 
an  opening  here,  it  may  be  covered  in  bj^  a  long  flap  turned  from  the  forehead 
and  the  pedicle  replaced  after  vascular  connections  have  been  established  between 
tlie  tissues  of  the  nose  and  the  transplanted  portion.  With  proper  care  the  resulting 
scar  upon  the  forehead  does  not  seriously  disfigure. 

When  the  integument  of  the  nares  is  intact  and  the  tip  of  the  nose  is  shriveled 
and  sunken,  the  employment  of  the  three-legged  platinum  support  or  ridgepole 
advocated  by  Dr.  Eobert  Weir  will  relieve  to  a  considerable  extent  the  deformity. 
The  upper  lip  and  nasal  attachments  are  lifted  freely  from  the  bones  of  the  face 
by  subcutaneous  dissection  with  curved  scissors,  commencing  along  the  attachment 
of  the  upper  lip  to  the  alveolus  of  the  superior  maxilla,  and  by  this  route  detaching 
the  alK  nasi  and  contiguous  integument  from  the  maxilla  and  nasal  bones.  The 
ridgepole  of  platinum  is  now  inserted  from  underneath  the  lip,  the  lateral  prongs 
or  legs  resting  uj^on  the  superior  maxilla  of  either  side,  while  the  upper  jjrong  rests 
between  the  skin  and  the  nasal  bones.  The  greatest  care  is  essential  to  prevent 
the  accidental  displacement  of  the  apparatus. 

Congenital  Lesions  of  the  Nose. — Occasionally  the  lateral  halves  of  the  nose  fail 
to  unite,  resulting  in  the  deformity  known  as  bifid  nose.  There  may  be  partial 
or  complete  absence  of  this  organ,  or  when  present  the  nares  may  be  occluded, 
or  it  may  be  complicated  with  the  extreme  cases  of  harelip.  The  operative  pro- 
cedure for  the  relief  of  this  last  deformity  will  be  given  in  connection  with  con- 
genital cleft  of  the  lip.  Occlusion  of  the  nares  may  be  relieved  by  cutting  through 
the  membrane  in  the  direction  of  the  normal  opening.  For  tlie  correction  of  forked 
nose,  or  the  absence  of  this  organ,  no  fixed  rule  of  practice  can  be  laid  down. 


CHAPTEK    XV 

THE    FACE,    LirS,    AND    CHEEKS,    PAROTID    GLAND    AND    DUCTS,    JA^YS    AND    TEETH 

Incised  wounds  of  the  face  usually  bleed  profusely.  The  essential  features  in 
treatment  are  to  arrest  hemorrhage  and  secure  repair  with  the  least  possible  cicatrix. 
When  the  bleeding  is  only  slight,  bringing  the  edges  together,  preferably  with 
horsehair  sutures  or  the  very  finest  celluloid  linen  will  arrest  it.  Should  a  ligature 
be  required,  the  finest  catgut  should  be  i\sed. 

Every  wound  of  the  face  should  be  treated  with  the  strictest  asepsis.  The 
approximation  of  the  edges  of  the  divided  skin  should  be  accomplished  with  exact- 
ness, and  the  sutures  carried  in  with  the  smallest  needles.  In  sujjerficial  incisions, 
after  the  haemorrhage  has  entirely  ceased,  the  edges  may  be  brought  in  apposition 
and  held  ))y  pressure  some  distance  from  the  wound  while  sterile  collodion  is  being 
freely  applied.  As  this  usually  contracts,  it  holds  the  wound  in  aj)position  without 
sutures. 

Contusions  of  this  region  require,  as  in  other  parts  of  the  body,  local  applica- 
tions, usually  of  cold  water  or  the  ice-bag.  EcchjTnosis  is,  as  a  rule,  present,  and 
is  persistent  in  the  tissues  'about  the  eyes. 

Lacerated  ivounds  of  the  face  are  serious,  on  account  of  the  danger  of  disfigure- 
ment after  repair.  If  the  procedure  does  not  involve  much  loss  of  tissue,  the  edges 
may  be  pared  smoothly  and  united  with  horsehair  sutures,  under  careful  asepsis. 
If  there  has  been  extensive  contusion,  a  small  catgut  drain  should  be  left  at  each 
end. 

Punctured  ivounds  require  no  special  consideration.  Deligation  of  the  external 
carotid  may  be  necessitated  to  arrest  bleeding  from  deep  wounds  of  the  spheno- 
maxillary fossa. 

Shot  wounds  of  the  face  are  not.  as  a  rule,  dangerous  to  life,  even  in  military 
practice.    In  civil  practice  the  rate  of  mortality  is  still  lower. 

When  the  missile  has  penetrated  tlie  spheno-maxillary  fossa,  or  divided  any 
deep-seated  vessels,  the  necessity  of  tying  the  external  carotid  may  arise.  A  ball 
or  any  foreign  body  lodged  in  the  bones  or  tissues  of  the  face  should  be  immediately 
removed,  when  this  can  be  accomplished  without  an  operation  which  may  incur 
the  danger  of  deformity.  When,  however,  the  missile  is  deeply  lodged,  and  is  of 
small  size,  it  should  not  be  molested  until  there  is  evidence  that  it  will  not  remain 
encapsuled  and  harmless. 

Bones  or  fragments  of  bone  which  have  been  displaced  in  part,  but  not  entirely 
stripped  of  periosteum  and  vascular  attachments,  must  not  be  removed,  since,  if 
replaced  and  held  in  proper  jDosition,  they  usually  become  reunited  to  the  sound 
bone. 

Accidental  wounds  of  the  lips  are  iisually  incised  or  lacerated.  If  badly  torn, 
the  ragged  edges  should  be  smoothly  trimmed,  washed  with  sublimate  solution,  and 
secured  with  interrupted  silk  sutures.  Wiien  the  wound  is  through  the  entire 
thiclmess  of  the  lip,  the  sutures  should  include  the  mucous  membrane.  A  very 
fine  suture  should  be  used  in  the  vermilion  border  to  insure  absolute  approximation 
here.    Adhesive  strips  are  not  reliable. 

Diseases  of  the  Lips. — Among  the  diseases  wliich  involve  the  lips  and  the  con- 
tiguous structures  are  epithelioma,  lupus,  papilloma,  nmvus,  cysts,  lipoma,  adenoma, 
phlegmon,  ulcers,  and  general  hypertrophy  and  fissures. 

Epithelioma. — One  of  the  most  frequent  causes  of  removal  of  portions  of  the 
lips  is  the  presence  of  epithelioma.    It  is  a  disease  of  middle  ajid  old  age,  involves 

.302 


FACE,  LIPS,  .\XD  CHEEKS,  PAROTID  GL.\:S"D  AXD  DUCTS,  JAWS  X\D  TEETH    303 

iisuallT  the  lower  lip,  and  occurs  in  the  great  majority  of  instances  in  males.  Ej:!- 
thelioma  mav  attack  the  lip  -n-ithout  any  appreciable  cause,  but  in  most  eases  the 
appearance  of  the  neoplasm  is  preceded  by  prolonged  irritation  at  the  place  in- 
Tolved.  A  jagged  or  projecting  tooth,  the  habitual  use  of  a  pipe  stem  or  cigar, 
are  frequent  causes  of  this  disease.  It  will  also  result  from  the  irritation  caiTsed 
by  chronic  fissure  or  ulcer  of  the  lip. 

Symptoms. — It  begins  as  a  small  ulcer  with  rather  abrupt  margins,  in  the  bot- 
tom of  which  is  a  dirty  granulation  tissue  partially  hidden  Ijy  tliin  pus.  In,  its 
earlier  stages  it  is  not  readily  distinguislied  from  the  Ijenign  ulcer  wliich  may  be 
found  upon  the  lip.  The  preceding  history  of  a  prolonged  irritation  should  always 
suggest  epithelioma,  especially  if  it  occurs  after  the  age  of  thirty-,  and  upon  the 
lower  lip.  Labial  chancre  may  be  diiferentiated  Ijy  the  indurated  base,  which  is 
characteristic  of  tliis  lesion.  Adenitis  in  the  line  of  IjTnphatics  along  the  lower 
jaw  comes  on  in  the  earlier  stages  of  syplulis,  while  in  epithelioma  the  sore  may 
exist  for  months  witliout  perceptible  enlargement  of  the  IjTnphatie  glands.  In 
sypliilis  the  appearance  of  the  eruption,  together  with  the  history  of  the  ease,  will 
lead  to  correct  differentiation. 

Epithelioma  of  the  lip  is  a  dangerous  affection.  Left  alone,  it  destroys  life 
within  a  period  varying  from  one  to  four  years.  It  spreads  at  times  with  rapidity, 
eating  away  the  tissues  in  all  directions.  It  may  confute  itself  to  the  soft  p^arts, 
or  attack  the  maxillary  and  nasal  bones.  Engorgement  of  the  submental,  sub- 
lingual, submaxillary,  and  cervical  glands  is  almost  inevitable  if  the  disease  is  not 
destroyed  in  the  first  few  months  of  its  existence.  The  glandular  enlargement  is 
at  first  not  always  due  to  metastasis,  l)ut  may  result  from  simple  adenitis  following 
the  infiammatory  process  in  the  margins  of  the  tilcer.  f 

Treatment. — Epithelioma  involving  mucous  or  muco-cutaneous  stirfaces,  espe- 
cially of  the  lips,  Intccal  cavity,  and  tongtte.  is  more  dangerous  by  reason  of  the 
tendency  to  rapid  glandular  infiltration  in  this  situation.  The  greatest  safetv  lies 
in  the  early  and  free  excision  of  the  diseased  tissues.  Marsden's  paste,  while  prefer- 
able in  epithelioma  of  the  skin,  is  in  general  second  to  the  knife  in  the  treatment 
of  this  disease  in  the  locality  under  consideration.  The  incision  should  he  well 
away  (about  half  an  inch)  from  the  infiltrated  margin,  and  if  any  Ivmjjhatic  glands 
are  enlarged,  they  should  be  thoroughly  extirpated.  In  closing  "the  gap  left  by 
removal  of  a  good  portion  of  lip,  the  principles  of  plastic  surgery  hereinafter 
given  sliould  be  employed  in  restoring  the  part  to  as  near  the  normal  condition 
as  possible. 

The  prognosis  as  to  permanent  cure  will  depend  in  great  part  upon  the  time 
which  has  elapsed  between  the  appearance  of  the  initial  epithelial  ulcer  and  the 
date  of  operation.  If  infiltration  of  the  lympliatic  channels  or  glands  has  occurred, 
these  should  he  thorottghly  removed.     Eecurrence  is  almost  inevitable. 

Lupus. — Lupus  erythvTnatosus  and  vulgaris  usually  attack  the  tissues  of  the 
nose,  cheeks,  and  lips,  at  times  producing  extensive  loss  of  substance.  The  ery- 
tliematous  variet}'  is  first  seen  as  small  red  papules,  projecting  slightly  above  the 
epidermis,  and  covered  with  scales.  It  is  a  disease  of  the  sebaceotis  glands  and 
ducts,  causing  clrronic  inflammation  of  the  skin  and  atrophy  of  all  the  elements 
of  the  cutis.  Its  progress  is  slow,  and  the  jjrognosis  is  usually  favorable  when  the 
disease  is  confined  to  a  limited  area.  It  does  not  afEect  the  general  health  of  the 
patient,  and  often  heals  spontaneously,  leaving  a  flat,  smooth  scar.  AYlien  dissemi- 
nated it  is  more  dangerous,  not  infrequently  ending  in  fatal  complications.  The 
treatment  requires  generous  diet,  tonics,  and  out-of-door  life.  Among  the  local 
agents  recommended  in  lupus  erythematosus  is  green  soap,  which  should  be  spread 
on  lint  and  pressed  closely  upon  the  affected  part,  or  rttbbed  in  with  the  finger 
every  day.  Prof.  A.  E.  Eobtnson.  in  addition  to  the  above,  also  recommends  a  ten- 
per-cent  solution  of  oleate  of  mercury  brushed  over  the  diseased  surface. 

If  the  disease  does  not  jield  to  these  milder  measures,  the  sharp  spoon  should  be 
employed  and  the  broken-down  tissue  thoroughly  scooped  out.  EmoUients,'  cold 
applications,  or  poultices  may  be  used  afterward,  according  to  the  requirements  of 
the  case. 

Lupus  vulgaris  is  a  more  formidable  affection.     In  its  earlier  stages  it  con- 


304    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 

sists  of  a  number  of  soft  red  dots  in  the  deeper  la^'ers  of  the  integument,  which 
gradually  ajjpear  as  papules  upon  the  surface.  The  characteristic  lesion  is  the 
infiltration  of  the  skin  with  an  abundant  small  cell  new-growth.  It  is  believed  to 
be  a  tuberci^losis  of  the  skin.  The  integument  breaks  dowTi  and  is  cast  oif  as  a 
slough.  The  new-formed  cells  also  undergo  granular  metamorphosis,  and  disappear 
with  the  other  destro3'ed  tissues.  Tlie  only  disease  likely  to  be  mistaken  for  com- 
mon lupus  in  the  adult  is  epithelioma.  Lujius  begins  usually  in  childhood,  while 
epithelioma  is  exceedingly  rare  before  the  age  of  thirty.  The  ulcer  of  lupus  is 
not  so  painful  as  that  of  epithelioma,  nor  its  edges  so  hard  and  elevated.  The 
treatment  of  this  affection  is  often  unavailing.  The  constitutional  treatment  is 
the  same  as  for  lupus  erythematosus.  Locally,  a  ten-per-cent  ointment  of  pyro- 
gallic  acid,  spread  upon  linen  and  closely  laid  upon  the  diseased  surface,  is  a  useful 
remedy.  It  should  be  applied  twice  daily  for  several  days,  and  then  poultices  or 
ointments  used  until  the  slough  is  removed.  In  certain  cases  it  is  advisable  to 
scrape  the  ulcer  well  with  a  sharp  spoon,  and  then  apply  the  pyrogallic  acid  for  one 
or  two  days.  Within  recent  years  the  X-ray  has  been  highly  recommended  as  a 
curative  agent.     The  jjrotection  of  all  parts  not  diseased  is  essential. 

Angeioma  of  the  lip  should  be  treated  by  the  injection  of  very  hot  water,  as 
already  described.  Should  cicatrization  result  the  deformity  may  be  corrected  by 
excision  and  a  plastic  operation. 

Moles  are  less  formidable,  and  rarely  require  an  extensive  reparative  operation 
after  excision. 

Papilloma,  lipoma.,  adenoma,  and  fibroma  do  not,  as  a  rule,  require  extensive 
incisions  and  loss  of  tissue  in  their  removal. 

Cystic  tumors  of  the  lip  are  not  infrequent,  occurring  as  spherical  swellings 
beneath  the  mucous  membrane.  They  are  caused  by  obstruction  of  the  duct  of  a 
laliial  follicle,  and  contain'  a  thick,  ropy  fluid.  The  treatment  involves  a  careful 
and  thorough  excision  of  the  sac. 

Fissures,  or  "  chaps  "  of  the  lip  may  occur  independently  of  any  constitutional 
disease.  They  may  be  cured  by  a  local  astringent,  as  alum,  or  caustic  nitrate 
of  silver,  apjjlied  once  a  day  for  two  .or  three  days.  When  these  more  simple 
remedies  are  without  avail,  excision  should  be  practiced.  When  fissure  of  the  lip 
is  allowed  to  remain,  and  the  general  condition  of  the  patient  is  bad,  necrosis  of 
the  mucous  membrane  immediately  contiguous  ensues,  causing  a  grayish-red  u.lcer. 
The  treatment  consists  in  the  local  use  of  astringents  and  the  improvement  of  the 
jDatient's  nutrition. 

Phlegmon  of  the  lip  is  rare.  It  is  a  painful  affection,  and  not  devoid  of  danger. 
The  pathology  of  carbuncle  has  been  given.  The  proper  treatment  is  early  and  free 
incision  through  the  skin,  deej)  fascia,  and  muscles,  and  the  emplojanent  of  aseptic 
poultices. 

Hypertrophy  of  the  lip  is  occasionally  met  with.  It  may  be  confined  to  the 
mucous  and  submucous  tissiies,  or  the  entire  thickness  of  the  lip  may  be  involved. 
It  occurs  usually  in  the  upper  lip,  but  may  l)e  seen  occasionally  in  the  lower  lip. 
When  extensive  enough  to  require  operative  interference,  the  proper  method  is  to 
dissect  out  in  the  long  axis  of  the  lip  a  jjortion  of  the  tissue  between  the  skin  and 
mucous  membrane,  and  approximate  the  edges  of  the  wound  with  silk  sutures. 

Hair  on  the  Lips  of  Women.- — Permanent  epilation  may  be  effected  by  intro- 
ducing into  tlie  follicle  of  each  hair  the. point  of  a  fine  platinum  needle,  which  is 
then  heated  by  the  galvanic  current.  The  employment  of  cocaine  renders  this 
operation  painless. 

Reparative  Surgery  of  the  Lips. — A  plastic  operation  may  be  demanded  in  ac- 
quired or  congenital  lack  of  tissue  in  the  upper  lip.  In  the  lower  lip  congenital 
deformity  is  exceedingly  rare. 

In  addition  to  congenital  defects  (harelip,  which  will  lie  considered  with  cleft 
palate)  as  the  result  of  accident  or  disease,  restoration  of  the  upper  lip  becomes 
necessary. 

When  the  defect  is  small  (Fig.  375)  the  flaps  are  shaped  by  the  incisions  a  d. 
The  lip  and  cheek  are  freely  dissected  from  the  maxilla  and  sutures  inserted  as 
shown  in  Pig.  376.     If  after  the  dissection  the  tension  is  still  so  great  that  the 


FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH    305 

parts  do  not  come  well  into  position,  a  horizontal  incision  should  be  made  on  either 
side,  beginning  near  the  root  of  tlie  nose,  and  carried  directly  outward,  or  slightly 
outward,  and  downward,  as  the  shape  of  the  flap  may  require.  Where  there  is 
greater  loss  of  substance  an  incision,  c  a  (Fig.  377),  is  carried  from  the  al*  of  the 


Fig.  375. — (After  Roser.) 


Fig.  376.— (After  Roser.) 


nose  upward  and  outward.  The  length  of  this  cut  and  its  obliquity  depend  upon 
the  distance  to  be  filled  between  the  normal  line  of  the  lip  and  the  nose.  A  second 
incision,  a  h,  is  now  carried  deeply  forward  and  outward,  making  a  quadri- 
lateral flap  which  hinges  at  b  d,  and  is  dissected  up,  and  the  edges,  c  a,  are 
brought  in  apposition  and  secured  to 
the  median  line.  Mk, 


Fig.  377. — (After  Linhart.) 


Fig.  378.— (After  Linhart.) 


Lower  Lip. — When  the  loss  of  tissue  has  left  a  cavity  triangular  in  shape,  as 
in  Pig.  378,  that  one  of  the  following  methods  may  be  selected  which  in  the  judg- 
ment of  the  operator  is  best  adapted  to  the  case: 

1.  A  horizontal  cut,  a  h  (Fig.  378),  is  made  outward  from  the  angle  of  the 
lip,  and  a  second  one,  &  c,  parallel  with  the  freshened  edge  of  the  fissure.  Both 
flaps  are  now  loosened  and  slid  toward  the  median  line,  and  united  by  sutures. 


Fig.  379. — (After  Szymanowsky.) 


Fig.  380. — (After  Szymanowsky.) 


Along  the  free  border  of  the  new  lip  stitch  the  mucous  membrane  to  the  skin  with 
fine  silk  sutures.  The  gap  left  on  either  side  is  also  wholly  or  partially  closed 
by  sutures  or  grafts. 


306    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS;  JAWS  AND  TEETH 

2.  If  the  fissure  is  less  extensive,  make  a  horizontal  incision  from  each  angle 
of  the  mouth  through  the  entire  thickness  of  the  lip  for  a  sufficient  distance  (Fig. 
379),  a  e.  c  d,  dissect  up  the  triangular  flaps,  and  adjust  with  sutures,  as  shown 
in  Fig.  380. 

3.  When  the  apex  of  the  triangular  defect  does  not  dip  down  too  far  from  the 
teeth,  the  unilateral  sliding  operation  of  Blasius  may  be  practiced.     From  the  apex 


Fig.  3S1. — (After  Szymanowsky.) 


Fig.  382. — (After  Szymanowsky.) 


of  the  angle,  c  (Fig.  381),  make  a  deep  cut,  c  e  d,  downward  and  outward  over 
the  side  of  the  chin,  in  the  main  a  continuation  of  the  line  of  the  defect,  h  f  c.  The 
flaj),  a  c  e  d,  \s  dissected  up  and  slid  so  that  c  is  attached  to  h  (Fig.  382). 

In  contraction  of  the  mouth  the  orifice  may  be  enlarged  by  incising  the  angles 
in  a  horizontal  direction,  finishing  the  operation  by  stitching  the  skin  and  mucous 
membrane  together. 

In  the  selection  of  any  of  the  plastic  methods  heretofore  given,  the  surgeon  must 
be  guided  by .  the  requirements  of  each  case.  It  is  a  wise  ijrecaution  to  make  a 
guarded  prognosis,  for,  no  matter  how  successful  from  the  surgical  standpoint,  the 
operations  do  not,  in  the  majority  of  instances,  secure  the  expected  improvement 
in  the  personal  appearance  of  the  patient. 

Very  extensive  defects  involving  the  lower  lip  and  chin  and  the  cheeks  may 
be  very  satisfactorily  repaired  by  various  modifications  of  this  sliding  method  of 
skin  transplantation.  It  is  especially  applicable  in  correcting  the  deformities  re- 
sulting from  cicatricial  contractions  after  burns.  The  lower  lip  may  be  drawn 
well  toward  the  lower  margin  of  the  jaw,  leaving  the  teeth  exposed  and  the  reten- 
tion of  saliva  imijossible.  The  cicatricial,  tissue  should  be  thoroughly  removed 
and  the  liberated  vermilion  border  of  the  lip  stitched  back  to  its  original  position. 
The  gap  left  open  is  then  filled  by  sliding  a  flap  of  suitable  size  from  the  neck. 
Careful  measurements  should  be  made,  and  if  necessary  a  chamois  pattern  should 
be  modeled  in  order  to  secure  accuracy.  The  shape  of  the  flap  must  conform 
to  that  of  the  space  to  be  filled.  The  defect  in  the  neck  is  in  turn  filled  by  a 
second  flap  from  below,  and  so  on  until  the  last  flap  and  scar  is  low  enough  to  be 
concealed  by  the  collar.  On  account  of  the  elasticity  of  the  flaps,  by  stretching  each 
somewhat  beyond  the  normal,  a  considerable  gain  is  made  in  covering  surface, 
until  by  the  time  the  chest  is  reached  the  gap  is  insignificant.  In  all  these  plastic 
procedures  not  only  is  asepsis  essential  to  rapid  and  satisfactory  repair,  but  the 
position  must  be  such  that  there  is  no  strain  on  the  sutures  or  tension  or  pressure 
on  the  flaps.     The  sutures  are  of  silkworm-gut  or  fine  linen  or  silk. 


Parotid  Gland  and  Duct 

Salivary  fistula  may  be  confined  to  the  main  parotid  duct  in  any  part  of  its 
course,  or  to  the  primary  drtcts  within  the  substance  of  the  gland. 

It  may  result  from  a  wound  or  any  inflammatory  and  necrotic  process  due  to 
obstruction  from  salivary  calculi  or  other  disease  of  the  parotid  and  buccal  regions. 
Exploration  of  the  duet  with  a  delicate  blunt  probe  is  accomplished  thus:  Find 
the  outlet  at  the  papilla  on  the  mucous  membrane  of  the  buccal  cavity  near  the 
junction  of  the  second  bicuspid  and  first  molar  teeth  of  the  upper  jaw.     Introduce 


FACE,  LIPS,  -\XD  CHEEKS,  P.^EOTID  GL.iXD  .\XD  DUCTS,  JAWS  .AN'D  TEETH     307 

the  probe,  caming  it  at  first  slightly  outward.  When  it  is  arrested  by  the  natural 
curve  of  the  duct,  pull  the  comer  of  the  mouth  and  the  cheek  directly  outward, 
thus  straightening  the  tube.  The  general  direction  is  backward,  toward  the  auditory 
meatus. 

The  diagnosis  of  salivary  fistula  or  of  obstructed  duct  may  be  determined  as 
follows :  By  means  of  absorbent  cotton  or  lint  remove  all  moisture  from  the  mucous 
surface  where  the  papilla  is  situated,  and  place  some  sapid  or  acid  substance  on 
the  tongue.  If  there  is  no  obstruction,  the  flow  of  saliva  is  immediately  perceived. 
In  ease  of  fistula  the  secretion  wLU  flow  out  through  it.  Calculi  of  Steno's  duct, 
or  of  any  of  the  salivary  ducts,  should  be  removed  by  dilatation,  if  this  is  possible, 
and  if  not,  by  incision.  The  prominent  feature  of  stone  is  swelling  of  the  cheek 
from  retention  of  saliva. 

In  the  treatment  of  salivarj-  fisttda  the  object  aimed  at  is  to  stop  the  flow 
of  saliva  on  the  outside  and  turn  it  into  the  mouth.  Arm  a  probe  with  a  sUk 
seton  and  carry  it  through  the  fistula  into  the  buccal  cavitv",  bring  the  thread 
out  through  the  mouth,  and  tie  the  tivo  ends  together.  In  about  ten  days  the 
flow  into  the  mouth  ^ill  be  fully  established,  when  the  seton  should  be  removed 
and  the  outer  opening  closed  by  a  compress  until  cicatrization  occurs.  It  may, 
at  times,  be  necessary  to  freshen  the  edges  and  bring  them  together  with  a 
suture. 

Eiberi  operated  successfully  by  cutting  tlirough  the  integument  down  iipon  the 
duct  behind  the  opening,  passing  a  ligature  around  it,  and  carrying  this  and  the 
end  of  the  duct  into  the  buccal  cavitv",  where  it  was  left  open.  The  wound  in 
the  integument  was  immediately  sutured. 

In  a  case  recently  treated  by  the  author,  the  following  method  was  successful 
in  restoring  the  flow  of  saliva  into  the  mouth :  A  boy  twelve  years  old  had  scarlatina 
at  seven,  which  was  followed  by  obstruction  of  the  left  duet  of  Steno.  A  fistulous 
opening  occurred  spontaneously  behind  the  ear.  Cutting  down  tlirough  the  cheek 
in  the  anatomical  line  of  the  duct,  this  was  discovered  to  be  obliterated  for  .the 
last  half  inch  of  its  course.  It  was  divided  just  posterior  to  the  limit  of  occlusion, 
and  an  incision  opposite  this  point  made  directly  through  into  the  buccal  cavity. 
Two  fine  silk  threads  were  inserted  in  the  wall  of  the  duct  at  the  end,  and  these 
sutures  were  stitched  to  the  mucous  membrane  of  the  cheek  at  the  edges  of  the 
incision  just  made.  The  wound  in  the  integument  of  the  face  was  closed,  excepting 
the  anterior  angle,  where  a  smaU  rubber  tube  was  inserted.  This  tube  projected 
into  the  cavity  of  the  mouth  by  the  side  of  the  new  opening  for  the  duet.  This 
was  done  to  form  a  fistula  in  case  the  wound  in  the  mucous  membrane  should  close 
and  obstruct  the  duct.  A  compress  was  placed  and  worn  on  the  fistulous  opening 
behind  the  ear.  The  tube  was  removed  in  five  weeks,  and  the  external  outlet  closed 
by  silk  sutures.  At  this  time,  also,  the  old  fistulous  opening  was  closed.  The 
saliva  up  to  this  time  flowed  about  equally  out  of  the  hole  behind  the  ear  and  the 
opening  in  front.  After  this  it  came  only  through  the  end  of  the  duct  in  the 
mouth. 

Fistula  of  the  primary  ducts  within  the  substance  of  the  gland  may  require 
the  forced  atrophy  or  ablation  of  this  organ.  An  effort  at  occlusion  should  be  made 
by  direct  pressure  upon  the  abnormal  opening,  or  by  careful  dissection  in  the  line 
of  the  fistula,  when  this  can  be  safely  done.  When,  however,  the  fistulous  tract 
is  deeply  situated,  it  will  be  found  almost  impossible  to  effect  a  cure  without  serious 
risk  of  interfering  with  the  integritv-  of  the  seventh  nerve,  the  motor  filaments  of 
which  are  in  intimate  relation  with  this  gland.  Eemoval  of  the  parotid  gland,  for 
any  cause,  becomes  a  serious  operation,  since  it  necessarily  implies  paralysis,  more  or 
less  complete,  of  the  muscles  of  the  face ;  when  it  is  entertataed,  the  patient  should 
be  thoroughly  acquainted  with  the  prospect  of  paralysis  wliich  will  follow.  In 
non-malignant  cases  the  greatest  care  should  be  exercised  in  avoiding  division  of 
the  filaments  of  the  facial  nerve.  Even  in  the  arrest  of  hemorrhage,  as  the  opera- 
tion proceeds^,  the  application  of  the  forceps  should  be  carefully  made,  so  that  the 
branches  of  the  nerve  may  not  be  injured  or  included  in  the  ligature.  When  the 
seat  of  malignant  disease,  a  thorough  ablation  is  essential,  and  the  nerve  is  neces- 
sarily sacrificed. 


308    FACE,  LIPS,  AKD  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 

Tumors  of  the  Parotid. — About  thirty  per  cent  of  all  neoplasms  of  this  organ 
are  enchondromata,  twenty-five  carcinomata,  while  the  remaining  forty-five  per  cent 
are  about  equally  divided  between  sarcomata,  fibromata,  myxomata,  and  cystomata. 
Enchondroma,  carcinoma,  and  fibroma  occasionally  are  found  developing  at  the 
same  time  in  this  organ.  Simple  hypertrophy  is  rare,  although  hyperplasia  of  the 
gland  tissue  occurs  in  a  varying  degree  in  the  progress  of  most  of  the  neoplasms 
which  attack  this  organ. 

Tumor  of  the  parotid  is  rare  prior  to  the  thirtieth  year  of  life,  being  met  with 
chiefly  between  the  thirtieth  and  fiftieth  years.  As  to  the  period  when  the  various 
forms  appear,  it  may  be  said  that  carcinoma  occurs  generally  after  the  fiftieth  year, 
while  enchondroma,  sarcoma,  m3'xoma,  and  fibroma  develop  in  the  earlier  decades. 
Sarcoma  is  apt  to  develop  in  childhood  or  early  adult  life. 

Diagnosis. — All  forms  of  tumor  of  the  jDarotid,  as  a  rule,  develop  slowly.  In 
the  earlier  stages  of  their  development  they  are  movable  within  the  limited  area  of 
mobility  of  the  gland.  This  is  true  of  both  the  benign  and  malignant  growths. 
Later,  even  the  benign  neoplasms  may  become  fastened  between  the  temporal  bone 
and  fascia  and  the  ramus  of  the  jaw,  but  not  to  the  overlying  integument.  The 
malignant  growths  are  more  rapid  in  development,  and  earlier  in  their  history  are 
bound  down  to  the  surrounding  tissues,  may  become  adherent  to  the  integument, 
and  produce  great  pain  and  disturbance  by  reason  of  pressure  upon  the  "nerves  and 
vessels  with  which  the  gland  is  in  close  relation. 

The  cartilage  tumors  are  nodular,  hard,  and  slightly  elastic  to  direct  pressure. 
Cancer  is  also  nodular  at  times,  but  not  so  hard  as  enchondroma.  Cancer  comes, 
as  a  rule,  after  the  forty-fifth  to  fiftieth  year,  and  the  other  neojDlasms  before  this 
period.  The  lymphatic  glands  are  involved  in  cancer,  and  rarely  enlarged  in  any 
other  form  of  neoplasm.  Sarcoma  occurs  earliest  of  all.  Cysts  are  elastic,  may 
present  fluctuation,  while  the  exact  character  of  this  variety  may  be  determined 
by  exploration  with  the  aspirator.  If  of  great  importance  in  determining  tlie  plan 
of  treatment  to  be  pursued,  a  section  of  the  diseased  organ  sufiiciently  large  for 
microscopic  examination  should  be  removed;  in  this  way  a  positive  diagnosis  is 
assured. 

Bern  oval  of  the  parotid  gland  is  a  difficult  operation.  In  many  cases  of  tumor 
of  this  organ  in  which  the  neoplasm  is  developed  at  the  expense  of  the  under  portion 
of  the  gland,  the  internal  jugular  vein,  internal  carotid  artery,  and  the  important 
nerves  and  ganglia  situated  here  become  so  involved  that  complete  extirpation  is 
impossible.  When  the  tumor  is  of  small  size,  it  may  be  entirely  removed.  Section 
of  the  various  divisions  of  the  facial  nerve  or  of  the  main  trunk  is  almost  inevitable. 

Operation. — Make  a  crucial  incision  over  the  mass,  the  perpendicular  cut  being 
in  the  line  of  the  external  carotid  artery.  Turn  the  flaps  back  from  the  anterior 
aspect  of  the  tumor,  and  approach  its  deeper  portions  from  below  in  the  line  of 
the  vessels.  As  soon  as  the  external  carotid  can  be  exposed,  it  should  be  secured 
with  a  catgut  ligature.  All  bleeding  should  be  arrested  as  the  operation  proceeds. 
The  reversed  Trendelenburg  posture  and  Dawbarn's  sequestration  will  aid  greatly 
in  diminishing  bleeding  and  the  recognition  of  the  nerve  filaments.  In  lifting  the 
under  surface  of  the  tumor  from  its  bed,  the  operator  should  keep  close  to  the  mass, 
using  a  dull  instrument  for  fear  of  wounding  the  internal  jugular  vein  and  other 
important  vessels  or  nerves.  The  blunt  scissors  curved  on  the  flat,  the  handle  of 
the  scalpel,  or  the  thumb  and  finger  nail  may  be  utilized  for  this  purpose.  The 
facial  nerve  and  its  branches  which  run  through  the  neoplasm  should  be  saved,  if 
possible.  As  before  stated,  if  the  tumor  is  extensive,  this  is  scarcely  possible  on 
account  of  the  gi-eat  length  of  time  it  would  require.  If,  in  the  course  of  the 
operation,  it  is  discovered  that  the  neoplasm  dips  down  beneath  the  jaw  and  sty- 
loid process,  and  surrounds  the  vessels  and  nerves,  its  complete  extirpation  is  im- 
possible. As  much  of  the  mass  as  can  be  lifted  should  now  be  transfixed  near  the 
middle  with  a  double  elastic  ligature,  tied,  and  the  part  external  to  the  ligature 
cut  away. 

The  -prognosis  in  cancer  and  sarcoma  of  the  parotid  is  always  grave,  even  after 
removal.  The  probabilities  of  recurrence,  and  the  certainty  of  facial  paralysis 
should  be  fully  explained  before  operation.     In  benign  tumors  which  show  a  tend- 


FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH    309 

eney  to  increase,  operation  should  be  advised.     It  is  always  important  to  attempt 
the  removal  of  the  neoplasm  early  in  its  history. 

In  sarcoma  and  in  all  doubtful  inoperable  tumors  the  injection  of  the  mixed 
toxines  as  advised  hj  Coley  should  be  faithfully  tried  before  extirpation  is  at- 
tempted. 

Parotitis — "  Mumps  " 

Inflammation  of  the  parotid  gland  occurs  chieflj^  in  children,  but  is  occasionally 
met  with  in  adults.  In  males  it  is,  at  times,  accompanied  by  orchitis,  and  in  females 
the  mammary  glands  and  ovaries  are  affected.  The  symptoms  are  pain  and  swell- 
ing of  the  gland,  difficult  deglutition,  and  slight  febrile  movement.  The  prog- 
nosis is  favorable,  the  disease  yielding  to  warm  applications,  quiet,  and  the 
judicious  employment  of  laxatives.  In  rare  instances  atrophy  of  the  testicle  has 
been  known  to  follow  the  inflammation  of  this  organ,  occurring  as  a  complication 
of  "  mumps." 

Abscess  of  this  organ  may  occur  as  a  complication  of  the  eruptive  or  continued 
fevers.  Under  these  last  conditions  the  prognosis  is  always  grave.  The  presence  of 
pus  is  recognized  by  the  intense  character  of  the  pain  experienced,  the  febrile  move- 
ment, the  dough}'  condition  of  the  skin  and  areolar  tissue  in  front  of  the  organ, 
and  by  aspiration.  The  abscess  should  be  evacuated  by  aspiration,  puncture,  or 
incision. 

SUBMAXILLAEY    GlaND 

This  organ  may  become  inflamed  and  suppurate,  or  be  the  seat  of  neoplasms. 
Its  removal  is  a  simple  procedure,  and  may  be  accomplished  by  a  crescentic  incision 
commencing  at  the  angle  of  the  jaw,  dipping  three  quarters  of  an  inch  toward 
the  hyoid  bone,  and  ending  one  and  a  half  inch  in  front  of  the  angle  at  the  lower 
border  of  the  jaw.  The  flap  of  skin  should  be  raised  with  the  platysma  muscle  as 
far  as  the  jaw,  and  the  deep  cervical  fascia  divided.  The  gland  rests  beneath  and 
internal  to  the  bone  and  upon  the  mylohyoid  and  hyogiossus  muscles.  The  sub- 
maxillary branch  of  the  facial  artery  may  be  divided. 

The  Jaws 

Superior  Maxilla. — Periostitis,  ostitis,  and  abscess  of  the  upper  jaw  may  be 
caused  by  infection  through  a  carious  tooth,  or  in  the  upper  jaw  from  the  antrum, 
or  pathological  changes  within  the  bone  proper.  Ostitis  of  the  maxilla  is  more  apt 
to  occur  in  children,  and  especially  in  those  of  a  tuberculous  diathesis.  Phosphorus 
poisoning  and  the  syploilitic  dyscrasia  lead  also  to  inflammation  and  caries  of  this 
bone. 

The  symptoms  of  ostitis  and  abscess  here  do  not  difl'er  from  those  already  given 
in  the  general  chapter  on  bone  diseases.  Pain  is,  perhaps,  more  acute  in  ostitis 
within  the  distribution  of  the  trifacial  nerve.  It  is  elicited  by  direct  pressrire,  and, 
when  the  process  is  associated  with  a  carious  tooth  or  its  roots,  the  exact  location 
may  lie  determined  by  striking  the  tooth  sharply  with  a  metallic  substance. 

The  treatment  is  to  relieve  the  tension  by  puncture  or  incision,  or  by  extraction 
of  one  or  more  teeth  in  case  they  are  connected  with  the  diseased  surface.  The 
removal  of  dead  bone  is  demanded.  When  exfoliation  has  occurred,  the  operation 
is  much  simplified.  If  free  drainage  is  secured  by  early  incision,  the  arrest  of. 
the  spread  of  the  disease  is  practically  insured.  Chronic  alveolar  abscess  is  often 
cured  by  extraction  of  an  offending  tooth.  Wlien  this  fails,  the  diseased  surface 
should  be  exposed  hj  incision,  and  a  thorough  removal  accomplished.  When  pos- 
sible, all  sequestra  should  be  removed  from  within  the  oral  cavity  in  order  to 
avoid  a  scar  upon  the  face. 

Syphilitic  ostitis,  and  that  variety  which  occurs  from  absorption  of  the  fumes 
of  phosphorus,  require  specific  constitutional  treatment  as  well  as  operative  inter- 
ference. 

Aliscess  of  the  antrum  of  Higlmiore  may  occur  as  the  result  of  an  inflammatory 
process  in.  the  mucous  membrane  lining  this  cavity,  by  extension  of  an  infection 


310    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 

from  the  nose,  or  in  connection  with  ostitis  of  the  upper  Jaw,  or  from  the  presence 
of  foreign  bodies  or  neoplasms  within  its  cavity.  The  chief  symptom  is  pain, 
referred  to  the  region  of  the  antrum.  The  febrile  movement  of  acute  abscess  is 
usually  present.  The  pus  may  force  its  way  through  the  opening  into  the  meatus, 
or  cause  necrosis  in  the  bone  and  discharge  in  any  direction. 

Treatment. — Free  drainage  must  be  established  in  all  cases.  This  can  be  accom- 
plished in  two  ways :  First,  and  preferably,  by  making  an  opening  directly  into  the 
antrum  from  beneatli  the  cheelc  and  Just  above  the  roots  of  the  first  molar  tooth. 
For  temj^orary  drainage  in  the  suppurating  antrum,  this  opening  will  suffice.  It 
may  be  enlarged  by  biting  away  a  portion  of  the  wall  of  the  antrum  aroiind  the 
hole  made  by  the  drill.  It  is  important  to  explore  the  cavity  with  the  probe  or 
finger  in  order  to  determine  the  presence  of  dead  iDone  or  any  tumor  or  other  offend- 
ing substance.  Drainage  must  be  maintained  until  the  discharge  of  pus  lias  ceased. 
The  old  method  of  drainage  was  to  extract  the  anterior  molar  tooth  and  break 
through  directly  into  the  antrum;  but,  on  account  of  the  annoyance  from  the  easy 
entrance  of  food  through  this  opening,  it  will  be  better  to  employ  the  higher 
drainage. 

Among  the  many  other  diseases  to  fl'hich  the  antrum  is  snl3ject  are  myxoma, 
fi.broma,  papilloma,  sarcoma,  and  carcinoma.  The  differentiation  of  these  growths 
is  extremely  difficult.  The  small  electric  arc  light  introduced  in  the  pharynx,  nose, 
or  mouth  will  illuminate  the  normal  antrum  and  tlms  aid  in  diagnosis.  When  doubt 
exists  as  to  the  character  of  the  neoplasm,  an  exploratory  operation  for  the  purpose 
of  positive  diagnosis  should  be  made. 

Operation  for  Removal  of  a  Tumor  from,  the  Antrum  of  Iiighm.ore. — For  the 
removal  of  small  neoplasms  of  the  antnim,  the  method  already  given  of  incision 
underneath  the  lip  and  cheek  and  above  the  roots  of  the  molar  tooth  will  be  found 
sufficient  as  advised  and  practiced  by  Prof.  Eobert  C.  Myles.  For  larger  growths, 
the  following  simple  metliod  I  have  found  extremely  satisfactory,  and  liave  re- 
moved through  this  incision  tmnors  entirely  filling  the  cavity  of  the  antrum  of 
Highmore,  and  projecting  into  the  nose  and  j)harynx.  A  horizontal  incision 
is  made  about  one  fourth  of  an  inch  below  and  parallel  with  the  inferior 
orbital  margin,  and  extending  from  the  outer  angle  of  the  orbit  to  near  the 
canthus  of  the  eye.  A  second  incision  Joins  the  inner  extremity  of  this  cut  at 
a  right  angle,  and  divides  all  the  tissues  down  to  the  bone,  extending  to  the  level 
of  the  wing  of  the  nose.  The  filaments  of  distribution  of  the  fifth  nerve  are  divided 
and  all  the  tissues  are  lifted  with  tlie  periosteum.  The  anterior  wall  of  the  antrum 
is  broken  through  by  a  small  chisel,  and  the  opening  enlarged  with  the  rongeur 
until  the  entire  anterior  wall  is  removed  piece  by  piece.  The  antrum  is  now  ex- 
posed, the  tumor  removed,  and  the  hasmorrhage  arrested  by  a  packing  with  gauze, 
■which  is  then  removed  and  the  wound  closed,  leaving  a  small  catgut  drain  at  the 
anterior  inferior  angle,  when  this  is  deemed  necessary.  The  loss  of  the  anterior 
wall  of  the  antrum  produces  very  little  deformity. 

When  a  nasoi^haryngeal  tu.mor  of  large  size  has  developed  into  the  antnun  and 
is  pressing  into  the  spheno-maxillary  fissure,  j^roducing  bulging  of  the  eye,  and 
into  the  zygomatic  and  pterygo-maxillary  fossa,  the  following  operative  method, 
which  was  first  performed  by  the  writer  in  1894,  may  be  employed:  In  the  patient 
upon  whom  it  was  first  done  the  tumor  was  a  large  vascular  fibroma  which  sprung 
from  the  base  of  the  pterygoid  process  of  the  sphenoid  bone,  filled  the  nasopharynx, 
and  had  broken  through  the  posterior  wall  of  the  antrum.  It  projected  upward 
into  the  sphenoid  fissure  and  zygomatic  and  pter3'go-maxillary  fossas.  The  eye 
was  pushed  well  out  of  the  socket  and  toward  the  nose,  and  the  cheek  and  temporal 
region  were  greatly  swollen.  The  patient  was  a  young  man,  nineteen  years  of  age, 
and  in  bad  condition  from  frequent  hanuorrhages  from  the  tumor,  loss  of  appetite, 
and  sleeplessness.' 

■  An  incision  was  made  beginning  along  the  temporal  arch  two  inches  back  of  the  outer  angle 
of  the  orbit,  following  the  temi^oral  arch  to  the  edge  of  the  orbital  cavity,  along  the  frontal  process 
of  the  malar  bone,  curving  parallel  with  and  ong-eighth  of  an  inch  from  the  orbital  margin,  until 
the  point  of  the  knife  reached  half  an  inch  to  the  inner  side  of  the  infra-orbital  foramen;  then 
downward  to  the  level  of  the  ala  nasi  and  outward  through  the  cheek  until  the  point  of  the  knife 
neared  the  opening  of  Steno's  duct  (Fig.  383).     This  incision  was  down  to  the  bone  from  the  point 


FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH    311 


Operation  foe  Eejioval  of  the  Upper  Jaw 

A  quarter  of  an  inch  below  the  inner  canthus  of  the  eye  commence  an  mcision 
and  carry  it  downward  along  the  naso-maxillary  groove,  curving  in  the  contour 
of  the  ala  nasi,  then  horizontally  beneath  the  ala  to  the  median  line  of  the  lip, 
where  it  turns  directly  downward,  dividing  the  lip  in  the  median  fissure.  From 
the  point  of  beginning  carry  a  second  incision  one  fourth  of  an  inch  below  and 
parallel  with  the  inferior  margin  of  the  orbit  out  to  the  prominence  of  the  inalar 
bone  (Fig.  384).  Dissect  up  the  soft  tissues  of  the  cheek,  and  turn  the  flap 
downward  and  outward.     If  the  disease  is  so  extensive  that  the  incision  does  not 

of  beginning  to  the  lower  point  of  the  superior  maxilla,  where  the  antrum  of  Highmore  rests  upon 
the  alveolar  process  of  the  upper  maxilla  opposite  the  first  molar  tooth.  Htemorrhage  was  care- 
fully stopped  throughout  the  entire  incision  by  pressure  and  by  ligating  with  catgut  the  larger 
vessels  which  were  divided,  but  the  soft  tissues  were  in  no  way  dissected  up  from  the  bone,  except 
when  it  became  necessary  to  enter  the  orbital  cavity  in  its  outer  half,  where  the  tissues  were  care- 
fully lifted  from  the  bone  and  the  eye  displaced  toward  the  median  line  (taking  care  not  to  press 
upon  or  injure  this  organ),  until  the  anterior  commissure  of  the  spheno-maxillary  fissure  came 
into  view.  I  then  passed  in  this  a  keyhole  saw  with  the  teeth  turned  upward,  and  sawed  through 
the  junction  of  the  malar  with  the  frontal  bone.  The  saw  was  then  turned  over  with  the  teeth 
directed  downward,  and  beginning  at 
the  same  point  I  rapidly  cut  through  the 
floor  of  the  orbital  cavity,  traversing  the 
infra-orbital  foramen  until  I  had  sawed 
through  the  antrum  of  Highmore  at  the 
level  of  the  alveolar  process  of  the  lower 
maxilla.  A  hook  was  then  placed  in  the 
outer  angle  of  the  orbit,  and  a  quick, 
sharp  jerk  fractured  the  zygomatic  proc- 
ess of  the  temporal  bone,  displacing  the 
side  of  the  face,  completely  exposing 
the  antrum  of  Highmore,  the  zygomatic 
fossa,  and  the  pterygoid  and  spheno- 
maxillary fissures.  The  haemorrhage  was 
severe,  but  was  controlled  by  packing 
sponges  into  the  wound  and  making  firm 
compression.  So  sudden  was  the  haemor- 
rhage that  the  pulse  jumped  from  85  to 
140,  and  the  patient,  who  was  before  the 
operation  in  a  condition  of  extreme  ex- 
haustion, seemed  about  to  expire  in  col- 
lapse. As  a  precautionary  measure  I  had 
inserted  into  the  median  cephalic  vein  a 
pipette  for  injecting  hot  salt  solution, 
and  had  everything  in  position  for  im- 
mediate use.  At  this  juncture  the  fau- 
cet was  turned  on,  and  one  pint  of  the 
saline  solution,  already  prepared  and 
kept  so  hot  that  the  hand  could  scarcely 
be  borne  in  it  with  comfort  (temperature 
110°  to  120°  F.),  allowed  to  run  into  the 
vein.  Under  the  pressure  of  this  solu- 
tion the  heart  rallied  and  came  down  to 
eighty-five  beats  to  the  minute.  The 
tumor  was  again  exposed,  and  with  a 
periosteal  elevator  lifted  out  of  the  an- 
trum of  Highmore,  and  from  its  attach- 
ments to  the  pterygoid  process  of  the 
sphenoid  bone.  By  opening  the  patient's 
mouth,  which  depressed  the  coronoid 
process  of  the  inferior  maxilla,  the  ptery- 
go-maxillary  fissure  and  the  zygomatic 

fossa  were  well  exposed.  The  whole  antrum  was  packed  with  a  long  wick  of  sterile  gauze,  which 
was  allowed  to  project  at  the  anterior  inferior  angle  of  the  wound,  from  which  it  was  drawn 
on  the  third  day  after  the  operation.  The  bone,  which  had  been  temporarily  displaced  with 
the  soft  parts  adherent,  was  then  brought  back  into  position  and  held  there  by  stitching  the 
soft  parts  along  the  line  of  incision.  A  bandage  and  compress  were  applied  in  order  to 
maintain  approximation.  No  sutures  were  inserted  in  the  bones.  The  patient  made  an 
uninterrupted  recovery.  He  is  now,  thirteen  years  after  the  operation,  entirely  well.  The 
bones  have  all  united  in  their  normal  position;  he  has  perfect  use  of  the  eye,  and,  although 
the  filaments  of  the  facial  nerve  were  di\'ided,  he  still  has  motion  of  the  orbicularis  palpebrarum 
muscle. 


/ 


Fig.  383. — Dotted  line  indicates  the  incision  for  the  au- 
thor's osteoplastic  resection  of  the  malar  bone  and  wall 
of  the  antrum  maxillare.  Case  of  Charles  Bull.  One 
year  after  operation. 


312    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 


expose  the  parts  sufficiently,  a  horizontal  cut  may  be  made  outward  from  the  angle 
of  the  mouth.     This  is  rarely  necessary. 

The  bone  may  be  divided  by  the  saw  inserted  in  the  spheno-maxillary  fissure, 
cutting  through  the  nasal  process  with  a  chisel.  Extract  an  incisor  tooth,  and 
with  a  chisel  or  bone-cutting  forceps  divide  the  alveo- 
lus and  the  palate  process  by  inserting  one  blade  in 
the  nose  and  the  other  in  the  mouth.  These  sections 
Jjeing  accomplished,  aviilsion  is  made  by  means  of  ele- 
vator and  forceps.  The  operation  is  completed  by  the 
closure  of  the  wounds  with  fine  silk  sutures.  If,  in 
section  of  the  palate,  the  Paquelin  cautery  is  used, 
hfemorrhage  will  be  less  annoying. 

Preliminary  tracheotomy  and  plugging  the  phar- 
3'nx  and  larynx  with  sponges  in  order  to  prevent  hEem- 
orrhage  into  the  trachea  is  rarely,  if  ever,  required. 

If  the  patient  be  placed  well  upon  the  side  and  the 
neck  twisted  over  so  that  the  mouth  is  dependent, 
the  blood  will  gravitate  easily  out  of  the  mouth,  and 
thus  dispense  with  the  necessity  for  a  trachea  tube. 
This  position  and  sequestration  should  be  employed 
in  all  cases  of  operation  xiimn  the  mouth  where  htem- 
orrhage  is  serious. 

For  simple  osteoma,  or  for  necrosis  of  the  upper 
jaw,  this  bone  may  be  removed  without  incision  in  the 
cheek.  I  removed  the  left  superior  maxilla,  except  the  orbital  plate,  entirely  from 
within  the  mouth,  without,  external  incision.  In  necrosis,  when  the  subperiosteal 
operation  is  permissible,  the  procedure  is  devoid  of  great  difficulty. 


The  Lower  Jaw 

Ostitis  of  the  inferior  maxilla  is  of  frequent  occurrence. 

Various  forms  of  fibroma,  fibro-myxoma,  encysted  fibroma,  enchondroma,  and, 
in  rare  instances,  angeioma,  have  been  observed  in  this  bone,  but  of  new  formations 
sarcoma  is  most  frequent.  Cystic  formations  resulting  from  failure  of  normal 
development  of  the  teeth  are  not  uncommon. 

Ostitis  occurs  most  frequently  in  children.  It  is  usually  secondary  to  disease 
of  the  teeth,  and  in  very  rare  instances  is  caused  by  inhalation  of  the  fumes  of 
phosphorus.  While  this  process  may  be  located  at  any  portion  of  the  jaw,  the 
neighlDorhood  of  the  angle  seems  to  be  most  frequently  affected. 

-    The  symptoms  are  pain,  followed  by  swelling  of  the  jaw  and  contiguous  soft 
tissue,  ending  in  abscess,  which,  if  left  alone,  eventually  opens  and  discharges. 

Treatment. — As  soon  as  the  character  of  the  disease  is  evident,  an  incision 
or  puncture  should  be  made  through  the  overlying  tissues  and  periosteum,  in 
order  to  give  free  exit  to  pus  and  loose  particles  of  bone.  The  operation  for 
removal  of  the  dead  bone  may  be  delayed  for  several  weeks  until  exfoliation  has 
taken  place.  Diligent  effort  should  be  made  to  reach  the  diseased  bone  from  within 
the  mouth,  and  this  can  be  done  in  a  large  proportion  of  cases.  With  the  patient 
well  over  on  the  side,  the  blood  will  flow  out  and  not  interfere  with  the  larynx. 
Incision,  when  necessary,  should  always  be  made  below  the  line  of  the  jaw,  if  this 
is  feasible,  so  that  the  resulting  scar  will  be  less  apparent.  Usually  by  following 
the  track  of  the  abscess  it  will  lead  directly  to  the  dead  bone  surrounded  by  an 
involucrum.  This  often  requires  to  be  chiseled  or  forced  open  to  allow  the  extrac- 
tion of  the  sequestrum,  which  may  be  readily  removed  with  ordinary  bone-  or 
dressing-forceps.  The  cavity  should  be  well  scraped  with  a  Volkmann's  spoon,  a 
drainage-tube  left  in,  and  the  edges  of  the  wound  adjusted  with  silk  sutures.  The 
deformity  due  to  the  rich  deposit  of  callus  disappears  with  the  absorption  of  this 
material.  When  all  or  any  portion  of  the  entire  thickness  of  the  jaw  requires 
removal  for  ostitis,  the  subperiosteal  operation  is  imperative,  since  by  this  means 
alone  is  it  possible  to  have  a  reproduction  of  the  bone.     The  method  of  procedure. 


FACE,  LIPS,  AND  CHEEKS,  P.AJtOTID  GL.^"D  .\XD  DUCTS,  JAWS  A>:D  TEETH     313 


when  the  bone  is  the  seat  of  a  neoplasm,  depends  upon  the  character  of  the  new 
formation.  If  there  is  any  doubt  as  to  the  benign  character  of  the  tumor,  a  piece 
should  be  removed  and  examined  microscopically  before  operation. 

In  sarcoma,  cancer,  and  enchondroma  of  the  Jaw,  the  subperiosteal  operation 
cannot  be  performed,  since  the  sound  tissues  must  be  included  in  the  ablation,  in 
order  to  secure  immunity  from  recurrence.  Enchondroma,  though  not  intrinsically 
malignant,  tends  to  recur  if  not  freely  excised.  In  the  experience  of  the  author, 
sarcoma  of  the  iipper  and  lower  jaw  is  not  so  apt  to  recur  as  in  other  bones. 

Operation. — When  it  is  safe  and  possible,  the  diseased  portion  of  the  lower  jaw 
should  be  removed  without  breaking  the  continuity  of  the  bone.  If  a  portion  of 
the  entire  thickness  of  the  organ  is  removed,  the  tendency  to  displacement  is  in- 
ward, thereby  interfering  with  mastication.  The  entire  tliiekness  of  the  jaw  should 
be  included  in  exseetion  lor  malignant  neoplasm. 

Eesection  of  the  lower  jaw  ma}-  be  accomplished  from  within  the  buccal  ca\ity, 
as  done  by  J.  Marion  Sims  in  18-15  (■"'  American  Journal  of  the  Medical  Sciences," 
October,  184:7).^ 

I  have  in  women  twice  performed  the  operation  of  dividing  the  inferior  maxilla 
in  the  middle  line  at  the  chin  with  the  wire  saw,  and  disarticulating  at  the  temporo- 
maxillary  joint  without  external  incision.  In  one  case  the  disease  was  osteomyelitis, 
and  the  operation  was  practically  subperiosteal.  Haemorrhage  was  insignificant. 
The  patient  recovered  with  very  slight  deformity,  as  shown  in  Fig.  385.  In  these 
eases,  as  soon  as  the  diseased  jawbone  is  removed,  in  order  to  prevent  displacement 
of  the  remaining  portion  toward  the 
median  line,  it  should  be  wired  to  the 
teeth  of  the  upper  jaw  and  held  in 
proper  position  itntil  the  wound  of  oper- 
ation has  healed  enough  to  permit  the 
insertion  of  an  artiticial  apparatus. 


Fig.  3S.5. — Complete  removal  by  disarticulation 
of  the  right  half  of  the  lower  jaw  from  within 
the  mouth.     Six  months  after  operatioru 


FiG.  3S6. — Osteo-sarcoma  of  inferior  maxilla.    Dis- 
articulation from  within  the  mouth. 


In  the  second  case  the  same  operation  was  successfully  performed  for  osteo- 
sarcoma. La  which  the  disease  was  as  yet  entirely  confined  to  the  central  portion 
of  the  left  half  of  the  inferior  maxilla  (Fig.  386).  Xo  effort  was  made  at  sub- 
periosteal removal,  as  it  was  essential  to  freely  dissect  away  with  the  mass  the 
soft  tissues  on  either  side.     The  girl  recovered,  and  one  year  after  the  operation 

'  Dr.  Sims  writes:  ■'There  are  several  considerations  to  recommend  this  operation  in  preference 
to  the  usual  one  with  its  extensive  incisions:  (1)  There  is  no  external  mutilation:  (2)  as  the  third 
branch  of  the  fifth  pair  of  nerves  was  di^-ided  at  the  outset  of  the  operation,  its  subsequent  stages 
were  comparatively  free  from  pain:  (3)  as  no  important  blood  vessels  are  cut,  no  ligatures  are 
recjuired:  (4)  there  is  no  trouble  with  the  after-treatment;  (5)  it  is  just  as  easy  of  performance 
as  the  old  operation." 


314    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 


there  was  no  sign  of  a  recurrence,  and  very  slight  deformity  (Fig.  387).  The 
danger  from  hemorrhage  is  slight,  and  the  flow  of  blood  into  the  larynx  can  be 
easily'  prevented  by  placing  the  patient  upon  the  side  corresponding  to  that  on 
which  the  operation  is  to  be  performed,  keeping  the  mouth  well  open  with  retractors, 
and  the  head  tilted  in  such  a  position  that  the  blood  runs  freely  out  of  the  mouth. 
Silk-suture  retractors  inserted  through  the  lip  at  various  points  in  the  entire  cir- 
cumference of  the  mouth  will  stretch  this  orifice  and  materially  aid  in  rapidity  of 
the  operation.  As  soon  as  the  disarticulation  is  completed  the  wound  should  be 
tightly  packed  with  sterile  gauze, 
in   order  to   arrest   haemorrhage. 


':x 


Y//    %, 


Fig.  387. — One  yezx  after  operation. 


Fig.  388. — (After  Roser.) 


When  the  danger  of  bleeding  is  past,  usually  in  fortj'-eight  hours,  the  packing 
should  be  removed,  and  not  replaced. 

If  there  is  extensive  malignant  disease  and  the  attachments  to  the  soft  parts 
are  firm,  the  intra-oral  operation  is  not  indicated,  and  external  incision  is  neces- 
sary. The  simplest  method  is  the  incision  of  Eoser  (Fig.  388)  through  the  median 
line  in  front  of  the  chin  and  underneath  the  jaw,  since  the  scar  is  less  prominent 
in  this  position. 

In  all  formidable  operations  about  the  mouth  where  rapid  work  is  imperative, 
Dawbarn's  sequestration  method  should  be  practiced,  and  morphine  should  be  given 
so  that  the  ether  inhaler  may  be  only  occasionally  required. 

Resection  of  the  inferior  dental  nerve  may  be  performed  at  the  mental  foramen, 
or  at  the  commencement  of  the  dental  canal  at  the  angle  of  the  Jaw. 

The  mental  foramen  is  situated  about  half-way  between  the  inferior  border  of 
the  bone  and  the  alveolus.  A  line  let  fall  perpendicularly  from  the  interspace 
between  the  two  bicuspid  teeth  of  the  lower  Jaw  will  pass  over  the  opening.  A 
curved  or  crucial  incision  will  expose  the  nerve  at  this  point. 

The  foramen  of  entrance  of  the  inferior  dental  nerve  is  very  near  the  center 
of  the  quadrilateral  formed  by  the  anterior  and  posterior  margins  of  the  ramus, 
the  lower  horizontal  border  of  the  angle,  and  an  imaginary  horizontal  line  on  a 
level  with  the  lowest  portion  of  the  sigmoid  notch. 

In  order  to  avoid  section  of  the  branches  of  the  facial  nerve  an  incision  as  long 
as  may  be  required  shotdd  be  made  along  the  lower  border  of  the  Jaw,  cutting 
directly  down  to  the  bone.  The  dissection  should  keep  close  to  the  bone,  clipping 
the  insertion  of  the  masseter  muscle  from  the  periosteum,  with  strong  upward 


FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH    315 

traction.  The  trephine  slrould  be  applied  over  the  center  of  the  quadrilateral.  The 
best  indication  of  having  reached  the  nerve  is  the  bleeding  through  the  track  of 
the  trephine  when  it  passes  into  the  cancellous  tissue  of  the  jaw.  This  comes 
fi-oni  the  wounded  inferior  dental  vessels.  An  elevator  placed  in  the  cut  will  now 
lift  the  button  of  bone,  and  expose  the  nerve.  The  entire  portion  in  the  limit  of  the 
trephine  should  be  excised.  Temporary  relief  is  almost  invariably  secured,  although 
a  recurrence  of  pain  is  not  uncommon  after  several  mouths.  Packing  the  dental 
canal  with  metallic  foil  is  advised  to  prevent  regeneration  and  reunion  of  the  nerve. 
As  before  stated,  the  exsection  of  the  Gasserian  ganglion  is  the  final  resort. 

Ankylosis. — Motion  of  the  Jaw  may  be  limited  or  entirely  prevented  by  mus- 
cular rigidity,  cicatricial  contractions,  or  true  ankylosis  at  the  temporo-maxillary 
articulation. 

The  area  of  motion  in  partial  ankylosis  may  be  increased  by  forcible  separation 
of  the  lower  from  the  upper  Jaw  by  the  mouth-gag  or  screw.  This  should  be 
repeated  at  frequent  intervals,  gradually  increasing  the  pressure.  In  severe  cases 
a  false  Joint  may  be  successfully  established  by  section  of  the  bone  anterior  to  the 
point  of  fixation,  usually  at  or  above  the  angle.  Care  must  be  taken  to  make 
frequent  passive  motion  in  order  to  prevent  bony  union  at  the  point  of  section. 

The  Teeth 

Extraction. — Dental  forceps  should  be  of  different  patterns,  the  Jaws  bent  at 
various  angles  to  the  shaft,  and  the  handles  large  enough  io  be  grasped  firmly  and 
securely  by  the  operator. 

The  gum  immediately  around  the  neck  of  the  tooth  should  be  freely  incised 
with  a  lancet,  since  if  this  precaution  is  not  taken  it  may  he  unnecessarily  torn 
away  with  the  tooth.  The  injection  of  cocaine  around  the  tooth  will  render  the 
cutting  painless,  while  nitrous-oxide  gas  should  be  given  for  the  extraction.     The 


Fig.  389. — Incisor,  straight  root. 

Jaws  of  the  forceps  are  applied  on  either  side  of  the  neck,  and  forced  down  toward 
the  root  until  they  grasp  the  tooth  firmly,  and  yet  not  forcibly  enough  to  cause 
crushing,  at  the  margin  of  its  alveolar  insertion.  The  direction  of  traction  is 
determined  by  the  normal  direction  of  the  axis  of  the  tooth.     In  extracting  the 


Fig.  390. — Incisor,  half-curved  root. 

incisors  and  canine  teeth,  the  forceps  represented  in  Figs.  389  and  390  are  applied 
as  described  above,  and.  when  firmly  fixed,  a  slight  forward  and  backward  move- 
ment, with  limited  rotation,  will  loosen  the  root,  while  traction  should  at  the 
same  time  be  made  in  a  direction  upward  and  slightly  forward  for  the  lower  Jaw, 
and  downward  for  the  teeth  of  the  upper  row.  For  the  bicuspids  and  molars,  the 
instruments  shown  in  Figs.  391,  393,  and  393  are  preferable. 

The  bicuspids  and  molars  may  be  loosened  by  lateral  motion  or  rocking.  The 
direction  of  traction  is  slightly  inward  for  the  lower  teeth,  and  slightly  outward 
for  those  of  the  upper  Jaw. 

Fracture  of  a  root  or  shelving  of  the  alveolus  will  occur  at  times  in  the  most 


316    FACE,  LIPS,  AND  CHEEKS,  PAROTID  GLAND  AND  DUCTS,  JAWS  AND  TEETH 

skillful  hands,  and  abscess  and  necrosis  may  ensue.  Fragments  of  the  teeth  should 
be  gouged  out  by  using  an  elevator.  Hajmorrhage,  usually  insignificant,  may  at 
times  be  dangerous,  death  having  occurred  from  this  cause  in  one  or  more  in- 


FiG.  391. — ^Wolverton's  upper  bicuspids. 


stances.  Cold  or  heat,  or  packing  the  cavity  with  a  compress  of  cotton  or  lint, 
will  effect  its  arrest.  In  extreme  cases  the  compress  may  be  saturated  with  Mon- 
sel's  solution,  or  alum,  or  any  astringent,  and  left  in  for  forty-eight  hours.    Nitrous 


Fig.  392. — Wolverton's  lower  bicuspids. 


oxide  may  be  employed  with  great  safety  in  dental  surgery.  A  number  of  fatal 
cases  are  recorded  in  which  chloroform  had  been  administered  in  extracting  teeth. 
Careful   attention   to   the  teeth   and   gums   is   an   essential   feature   of   preventive 


Fig.  393. — Harris'  lower  molars,  for  the  two  sides. 

medicine.  Malignant  neoplasms  are  frequently  caused  by  the  irritation  from  pro- 
jecting teeth.  Tuberculous  and  pyogenic  infection  is  a  common  occurrence  from 
exposed  abrasions  in  the  mouth. 

Dentigerous  cysts,  resulting  from  defective  development  of  the  teeth,  are  occa- 
sionally present.  They  appear  as  round  or  sessile  swellings  of  the  alveolus  or  jaw- 
bone near  the  roots  of  the  teeth.  As  the  covering  of  bone  is  thin,  it  gives  under 
pressure  with  the  finger  a  feeling  of  resiliency.  If  not  subjected  to  operation  early, 
they  lead  to  extensive  deformity,  and  tend  to  undergo  malignant  transformation. 
•  From  an  incision  within  the  mouth  they  can' be  exposed,  and  by  breaking 
through  the  soft  curtain  of  bone  the  cyst  is  opened  and  the  glairy  contents  escape. 
The  sac  should  be  carefully  removed  by  dissection  and  the  cavity  mopped  with  pure 
carbolic  acid  on  a  wisp  of  cotton.  Any  misplaced  tooth  should  be  removed.  A 
gauze  pack  should  be  inserted,  and  renewed  as  required  until  the  cavity  is  closed 
by  granulation.  The  process  is  usually  tedious,  and  requires  care  and  patience  on 
the  part  of  the  surgeon  and  patient. 


CHAPTER    XYI 


THE    UYULA,    DISEASES     OF    THE    PALATE,     CLEFT    PALATE     AXD    HARELIP,    TONGUE, 
BUCCAL    CAVITY,    AND    TONSIL 

Uvula. — On  account  of  elongation  or  h^ypertroph}'  of  this  portion  of  the  soft 
palate,  its  excision  is  at  times  required.  It  may  be  accomplished  by  taking  hold  of 
the  tip  with  a  mouse-tooth  forceps,  and  -with  a  long  curved  scissors  removing  as 
much  as  required.  Local  anesthesia  may  be  obtained  by  mopping  the  uvula  with 
a  small  quantit}'  of  a  four-per-cent  solution  of  cocaine  hydrochlorate  at  intervals 
of  three  minutes  for  fifteen  minutes  before  the  operation. 

Tumors  of  the  palate,  abscess,  necrosis,  and  ulceration  are  not  infrequent,  and 
demand  the  same  treatment  as  in  other  portions  of  the  body. 

Malignant  neoplasms  of  the  palate  should  be  thoroughly  destroyed  by  the 
Paquelin  cautery.  In  two  eases  which  came  under  my  care  this  was  done  with 
no  recurrence  in  five  years  and  one  year  respectively. 

Since  harelip  is  so  frequently  complicated  with  cleft  palate,  and  since  the  suc- 
cess of  any  operation  for  the  correction  of  a  deformity  caused  by  harelip  must 
depend  upon  a  reconstruction  of  the  alveolar  arch,  naturally  a  consideration  of 
the  cleft  palate  should  precede  that  of  the  deformity  of  the  lip. 

Cleft  palate  may  be  complete  or  incomplete,  lateral  or  bilateral.  The  fissure 
may  occupy  only  the  anterior  or  the  posterior  portion,  or,  in  rare  instances,  there 
may  be  only  a  cleft  in  the  uvula  or  velum  pendulum  palati.  It  is  almost  invariably 
congenital,  and  is  not  caused  so  much  by  a  deficiency  in  the  blastodermic  cells 
which  enter  into  the  formation  of  the  bones  of  the  roof  of  the  mouth  and  the 
floor  of  the  nose,  as  by  the  spreading  apart  of  the  two  superior  maxillffi  during 
the  formative  period. 

The  rare  cases  of  acquired  cleft  palate  are  due  usually  to  syphilis  or  to  non- 
specific necrosis  of  the  hard  palate. 

An  illustration  of  unilateral  cleft  of  the  palate  is  shown  in  Fig.  39-1,  while  a 
complete  bilateral  cleft  is  shown  in  Fig.  395.     In  the  latter  figure  it  will  be  ob- 
served that  the  intermaxillary  bone,  that 
portion  of  the  alveolar  arch   from  which 
the  four  upper  incisor  teeth  normally  pro- 
trude, is  attached  to   the  vomer,   and  is 


Fig.  394.— (After  Koenig.) 


Fig.  395. — (After  Koenig.) 


318      THE   UVULA,   DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC. 


projected  far  beyond  the  normal  contour  of  the  arch,  while,  in  the  preceding  figure, 
the  intermaxillary  bone  is  attached  to  the  alveolar  arch  on  one  side,  being  deflected 
from  the  median  line  toward  that  side,  while,  as  is  the  rule  in  practically  all  these 
cases,  the  fissure  is  exaggerated  by  a  deflection  outward  of  both  of  the  superior 
maxillae.  The  same  condition  is  shown  in  Fig.  396,  where  the  vomer  is  seen  to 
occupy  its  proper  place  in  the  median  line,  while  each  alveolus  is  abnormally 
divergent.  A  careful  study  of  these  abnormalities  must  convince  the  operator  that 
no  procedure  intended  to  correct  the  deformity  in  the  lip  and  nostril  (for  the  ala 
nasi  is  always  involved  in  these  displacements)  which  does  not  take  into  considera- 
tion the  necessity  for  a  more  or  less  perfect  reconstruction  of  the  bony  framework, 
can  give  a  satisfactory  result. 

In  the  newly  born  with  cleft  jDalate,  it  will  be  noticed  that  pressure  of  the  lower 
jaw  upward  tends  to  increase  the  space  Ijctween  the  already  separated  maxillre, 
while  even  light  pressure  with  the  thumb  and  finger  upon  the  cheeks  will  partially 
or  completely  close  the  fissure.  From  this  it  is  evident  that  the  proper  time  to 
commence  the  treatment  of  this  deformity  is  immediately  after  birth,  and  no  opera- 
tion upon  the  lips  or  nose  should  be  undertaken  until  the  best  possible  correction 
of  the  deformity  of  the  bones  has  been  made. 

In  bilateral  cleft  (Fig.  395),  the  first  step  of  importance  is  to  bring  the  pro- 
jecting intermaxillary  bone  back  into  its  normal  jilaee  in  the  alveolar  arch.     This 


Fig.  396. — Showing  at  clotted  line  where  the  alveolar 
process  is  divided  prior  to  advancement. 


Fig.  397. — Brophy's  strong  needles  used 
in  the  introduction  of  silver  tension 
sutures  through  the  maxillary  bones. 


may  be  done  in  very  young  infants  by  pressure  with  the  thumb  directly  backward, 
the  force  employed  crushing  the  vomer,  or  it  may  be  necessary,  with  strong  scissors, 
to  cut  the  lower  thickened  portion  of  this  bone,  permitting  it  to  overlap  as  the 
prominence  is  piushed  back  into  position.  It  is  not  advisable  to  cut  out  a  triangular 
section.  Once  restored  to  its  normal  position,  it  should  be  held  in  place  by  the 
proper  insertion  of  silver  wire  sutures. 

Lateral  compression  to  approximate  the  two  separated  superior  maxillse  may 
in  many  instances  be  continued  until  complete  union  occurs;  while  in  others,  espe- 
cially in  cases  that  have  not  been  operated  upon  early  in  life,  it  will  be  found  that 
if  lateral  compression  be  continued  until  the  fissure  is  closed,  the  alveolus  of  the 
upper  jaw  will  not  be  accurately  in  contact  with  the  lower.  The  operator  must 
guard  against  this  error,  and  while  a  slight  absence  of  alignment  may  be  permis- 
sible, it  should  not  be  too  great.  The  method  here  recommended  is  that  practiced 
by  Dr.  Truman  W.  Brophy,  which  is  as  follows : 

Beginning  within  a  few  days  after  birth,  a  lead  plate  should  be  carefully  fitted 
to  the  outer  contour  of  eacli  alveolar  arch,  and  through  this  there  should  be  as  many 
perforations  as  may  be  needed  to  accommodate  the  silver  wire  sutures.  In  complete 
cleft  four  sutures  are  usually  required,  while  in  a  partial  separation  only  two  may 


THE   UVULA,   DISEASES   OF  THE   PALATE/HARELIP,  TONGUE,   ETC.      319 


siiffiee.  A  strong  needle  (Fig.  397),  threaded  with  silk,  is  forced  through  the  soft 
bones,  passing  just  above  the  iioor  of  the  nose,  and  by  means  of  this  silk  thread  the 
silver  wire  sutures  are  carried  into  place.  The  ends  of  the  two  sutures  of  each  of 
the  two  sets  are  brought  through  the  lead  plates,  underneath  the  buccal  wall,  and 
while  lateral  compression  is  made  upon  the  superior  maxillte,  the  ends  are  tightly 
twisted  and  the  edges  of  the  fissure  approximated.  In  patients  between  five  and 
six  months  of  age  this  tightening  process  may  be  repeated  once  or  twice  each  week, 
making  an  additional  twist  upon  one  or  both  ends  of  the  sutures.  The  relation 
of  the  suttu-es  to  the  alveolar  arch  and  the  floor  of  the  nose  are  showTi  in  the 
schematic  diagrams  398  and  399.  The  bones  approximated,  the  operation  upon 
the  soft  parts  can  be  most  successfully  performed  when  the  child  is  aljout  fourteen 
to  eighteen  months  old.  Among  the  advantages  given  by  Dr.  Brophy  in  favor  of 
early  operation  are  the  following: 

(a)  The  surgical  shock  is  less  in  an  infant.  (&)  Before  the  bones  are  hard- 
ened, they  may  be  bent  or  moved  without  fracture,  (c)  If  the  muscles  are  brought 
into  action  early,  they  develop  instead  of  undergoing  atrophj'  from  disuse,  and 
hence  a  good  velum  is  secitred  with  plenty  of  tissue.  Xone  of  the  muscles  of  the 
soft  palate  can  be  developed  when  the  parts  are  not  united,  (d)  As  a  consequence 
of  early  operation,  there  is  much  less  deformity,  (e)  A  most  beneficial  result  of 
an  early  operation  is  that  it  permits 
a  normal  development  of  the  speech 
function. 


Fig.  398. — Vertical  section  of  the  superior  max- 
illary' bones  of  a  child  five  weeks  of  age,  show- 
ing congenital  cleft  palate,  a,  a,  silver  ten- 
sion sutures;  b,  b,  lead  plates;  c,  c,  germs  of 
the  first  temporary  molar  teeth ;  D,  cleft  palate. 


Fig.  399. — Palatal  surface  of  adult's  mouth, 
showing  congenital  cleft  of  the  hard  and 
soft  palates,  plates  and  sutures  in  position 
ready  for  tightening.      (Brophy.) 


In  dealing  with  delaj-ed  cases — i.  e.,  adults — while  a  perfect  restoration  of  the 
palate  is  possible,  the  faulty  habits  of  speech  are  so  fi:sed  that  even  with  special 
treatment  in  phonation  it  is  often  very  difficult  to  overcome  speech  defect.  In  all 
cases,  however,  it  is  important,  as  soon  as  possible,  to  place  the  patient  under  the 
special  instructions  and  care  of  a  speech  specialist. 

The  operation  upon  the  yormg  does  not  differ  materially  from  that  advised  for 
adults,  which  will  be  first  described.  Fig.  399  illustrates  a  congenital  cleft  of  the 
hard  and  soft  palates  in  an  adult.     Dr.  Brophy's  operation  is  as  follows: 

Beginning  at  the  edge  of  the  cleft  on  either  side,  the  periosteum,  together  with 
its  covering  of  mucous  membrane,  is  lifted  for  the  whole  length  of  the  palate  well 
back  to  the  alveolar  arch,  and  the  attachment  of  the  soft  parts  to  the  posterior 
margins  of  the  horizontal  portion  of  the  palate  bones  is  divided  so  that  the  mucous 
membrane  and  the  periosteum  lining  the  roof  of  the  mouth,  together  with  the 
uvula  and  the  muscles  of  the  palate,  are  entirely  loosened  (Fig.  400).  This  is 
best  accomplished  with  Brophy's  periosteotomes,  which  instruments  (Fig.  401) 
have  different  angles,  sttited  to  the  dii?erent  shapes  of  the  palate. 

The  next  step  is  to  freshen  the  edges  of  these  two  curtains  throughout  their 


320      THE  UVULA,   DISEASES  OF  THE  PALATE,   HARELIP,  TONGUE,   ETC. 

entire  length.  In  the  majority  of  cases,  if  this  operation  is  properly  done,  the  soft 
parts  readily  come  together  in  the  middle  line  without  undue  tension,  and  there 
is  no  necessity  for  making  lateral  incisions.  Two  narrow  lead  plates,  as  shown  in 
Fig.  403,  are  now  fitted  to  each  half  of  the  loosened  palate,  and  perforated  in 


FiQ.  400. — -Left  superior  maxillary  bone  with  associative  parts,  illus- 
trating surgery  of  the  palate  ;  A,  Posterior  border  of  horizontal 
plate  of  left  palate  bone  ;  e,  velum  separated  from  muco-perios- 
teum  of  nasal  surface  of  palate  bone  ;  c,  velum  separated  from  the 
hard  palate,  and  the  palate  lengthened  so  as  to  restore  palatal 
function  ;  d,  periosteum  denuded  from  hard  palate  ;  E,  palatal 
mucous  membrane  ;  f,  bones  denuded  of  membrane ;  G,  nasal 
muco-periosteum  ;  h,  position  occupied  by  palate  before  opera- 
tion;  I,  posterior  wall  of  the  pharynx.      (After  Brophy.) 


Fig.  401. — Brophy's  curved 
periosteotomes  used  in 
the  elevation  of  the  soft 
tissue  of  the  hard  pal- 
ate. There  are  a  num- 
ber of  these  instruments, 
varying  from  a  right  an- 
gle to  the  acute  angle 
shown  in  the  drawing. 


four  places  to  admit  the  passage  of  a  permanent  silver  wire  suture.  With  a 
proper  curved  needle,  as  shown  in  Fig.  403,  four  silk  sutures  are  carried  through 
the  tissues,  and  these  are  to  be  used  for  the  purpose  of  drawing  the  silver  wire 
(No.  22)    into  place.     They  are  temporarily  left  long  and  in  place  until  small 

coaptation  sutures  of  horse- 
hair or  gutta-percha  linen 
are  inserted.  The  two  pairs 
of  silver  wire  sutures   are 


^^ 


Fig.  402. — Palatal  surface  of  adult's  mouth  after  the  sutures 
have  been  tightened,  the  muco-periosteum  approximated, 
and  the  coaptation  sutures  tied;  a,  a,  lead  plates;  b,  closed 
palate;  c,  coaptation  sutures.     (Brophy.) 


Fig.  403.  —  Deschamp's  needles 
used  in  the  introduction  of  the 
sutures.      (Brophy.) 


then  drawn  into  place  and  twisted  over  the  plates  until  the  proper  degree  of  coap- 
tation and  tension  is  secured. 

The  space  left  between  the  loosened  lining  membrane  of  the  roof  of  the  mouth 
and  the  two  shelves  of  the  hard  palate  will  eventually  be  filled  in  by  new  bone, 
or  as  a  result  of  new  connective-tissue  formation  the  united  soft  parts  will  readjust 
themselves  in  contact  with  the  bone. 


THE   UVULA,    DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC.      321 

The  lead  plates  pressing  upon  such  a  broad  extent  of  surface  prevent  the  cut- 
ting out  of  the  tension  sutures.  They  also  serve  as  splints,  rendering  the  palate 
immovable  during  the  process  of  repair.  The  horse-hair  sutures  may  be  removed 
on  the  eighth  or  tenth  daj',  and  the  tension  sutures  at  the  end  of  ten  days  or  two 
weeks. 

The  proper  after-care  of  these  cases  is  very  important,  and  no  ingesta  should 
be  permitted  to  come  in  contact  with  the  line  of  union. 

When,  after  an  operation,  or  as  a  result  of  accident,  the  soft  palate  has  not  a 
suiBcient  length  to  perform  its  functions,  this  defect  may  be  overcome  by  a  plastic 


Pig.  404. — Drawing  from  life  showing  congenital 
defect  of  velum,  and  complete  absence.of  azy- 
gos  uvula  (a).      (Brophy.) 


Fig.  405. — Drawing  from  life  of  the  same  case 
after  operation  for  lengthening  velum  and 
making  uvula  by  uniting  in  the  center  one 
half  of  the  overdeveloped  palato-pharyngeal 
muscles  (-i).  . 


operation  on  the  palato-pharyngeal  muscles,  as  advised  by  Dr.  Brophy.  These 
muscles  may  be  seen  as  broad,  flattened  bands  of  muscular  tissue,  extending  from 
the  palate  downward  and  outward,  to  be  inserted  in  the  jDosterior  part  of  the  thyroid 
cartilage  (Fig.  40-i).  By  utilizing  two  thirds  of  each  muscle,  and  bringing  these 
flaps  to  the  median  line,  and  irniting  them  by  sutures,  the  palate  may  be  lengthened 
as  required  (Fig.  405). 

H.VEELIP 

Harelip  is  a  congenital  defect  in  which  the  upper  lip  in  one  or  two  places  is 
partially  or  completely  divided  in  thfe  embryonic  tissues  from  which  it  is  developed. 
This  deformity  is  ustaally  single  and  to  one  side  of  the  median  line.  According 
to  Dr.  Brophy,  eight.y-five  per  cent  of  single  harelip  cases  are  on  the  left  side.  A 
cleft  in  the  median  line  is  a  rare  exception. 

Harelip  is  complete  when  the  fissure  connects  with  the  naris  (Fig.  412),  incom- 
plete as  shown  in  Fig.  410.  It  may  or  may  not  be  complicated  with  a  partial  cleft 
of  the  hard  palate  and  alveolus.  Double  harelip  (Fig.  415)  almost  always  occurs 
vs^ith  cleft  of  the  hard  and  soft  palates.  Wlien  the  line  of  separation  communicates 
with  the  nostril  or  approaches  it,  even  when  there  is  no  cleft  of  the  bone,  the  nostril 
of  that  side  is  always  larger  than  its  fellow,  wliile  the  nose  is  drawn  over  in  the 
opposite  direction. 

As  stated  in  the  article  on  cleft  palate,  no  operation  should  be  attempted  on 
the  lip  until  the  alveolar  arch  has  been  reconstructed  and  the  cleft  in  tlie  palate 
closed.  When  this  has  been  done,  or  when  an  uncomplicated  harelip  is  present, 
the  following  methods  of  operation  are  advised: 

In  the  simpler  form  shown  in  Fig.  407.  where  the  nose  is  not  involved,  the  nick 
in  the  vermilion  border  may  be  obliterated  by  making  a  curved  incision  practically 
parallel  with  the  contour  of  the  nick  and  about  three  sixteentlis  of  an  inch  from  it, 
as  shown  in  the  illustration.     This  incision  should  be  made  with  a  very  narrow 


322      THE   UVULA,    DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC. 

knife,  wliieli  is  carried  directly  backward  througli  tlie  entire  thickness  of  the  lip. 
Bleeding  may  be  readily  controlled  by  having  an  assistant  grasp  the  lip  at  the  angles 
of  the  mouth  between  the  thumb  and  the  finger  of  each  hand.     If  the  lip  is  in 

any  way  adherent  to  the  gum,  it  should 
be  thoroughly  dissected  loose  with  the 


Fig    407  Fig.  408.— (After  Koeirig.) 

scissors.  A  tenaculum  is  then  inserted  in  the  center  of  the  incision,  and  the  strip 
drawn  down  as  shown  in  Fig.  408.  The  sutures  are  next  inserted,  passing  squarely 
through  the  entire  thickness  of  the  lip,  and  about  one  eighth  of  an  inch  away  from 
the  margin  of  the  incision.  When  there  is  practically  no  tension  in  these  minor  pro- 
cedures, horsehair  is  preferable.  The  '  ...._.  ,_.,,.. 
first  suture  should  be  inserted  as  indi-                                 .lillf       :|iBift 


Fig.  409. — (After  Nelaton,  Koenig.)  Fig.  410. 

cated  by  the  arrows  in  Fig.  408,  while  one  or  more  may  be  required  above  and  below 
this  point.  It  is  usually  advisable  to  insert  them  with  a  fine  needle  and  at  intervals- 
of  about  one  eighth  of  an  inch.     No  dressing  should  be  applied,  and  every  efllort 


should  be  made  to  prevent  infection.  In  the  case  of  a  child,  the  anns  and  hands 
should  be  confined  within  an  undervest,  so  that  they  cannot  disturb  the  sutures. 
The  patient  should  be  fed  with  a  spoon,  and  under  no  circumstances  should  be 
permitted  to  nurse  or  feed  from  a  bottle. 


THE   UVULA,   DISEASES   OF  THE   PALATE,   HARELIP,   TONGUE,   ETC.       323 


In  the  second  form  of  single  harelip  (Fig.  409)  practically  the  same  operation 
is  indicated,  the  incision  extending  somewhat  further  than  for  the  preceding  form. 
After  the  cut  is  commenced  it  is  well  to  insert  the  tenaculum  and  draw  down  the 
strip,  in  order  to  see  Just  what  may  be  the  shortest  possible  limit  of  the  incision. 
When  the  fissure  extends  higher,  as  shown  in  Fig.  410,  and  especially  in  the  com- 
plete form  (Fig.  412),  a  more  extensive  operation  is  indicated.  As  the  fissure 
approaches  the  nostril,  or  when  it  communicates  with  it,  the  first  step  in  the 
operation  is  to  dissect  the  lip  freely  along  the  lower  level  of  the  nose  as  high  as 
the  septum,  and  to  the  edge  of  the  nostril  of  the  unaffected  side,  while  the  nostril 
of  the  flattened  or  affected  side  should  be  freely  lifted  from  the  underlying  maxilla. 
The  operation  for  the  form  of  harelip  shown  in  Fig.  410  is  indicated  in  the  draw- 
ing. The  margin  of  the  fissure  should  be  freshened  through  the  entire  thickness 
of  the  muco-cutaneous  tissues  for  one  third  of  the  distance  from  the  angle  of  the 
cleft  toward  the  normal  level  of  the  vermilion  border.  From  this  point  an  incision 
is  made  outward  through  the  entire  thickness  of  the  lip,'  as  shown  in  the  drawing, 
the  flap  on  the  long  side  of  the  lip  being  made  longer.  In  making  these  incisions, 
the  operator  should  feel  his  way  by  fitting  the  flaps  from  time  to  time,  in  order 
to  avoid  cutting  farther  than  is  necessary. 

In  all  these  procedures  the  new-made  lip  should  project  a  little  beyond  the  level 
of  the  vermilion  border,  since  a  certain  amount  of  atrophy  will  always  take  place. 
In  an  operation  of  this  character  ( Fig.  410)  one  or  two  sutures  of  gutta-percha  linen 
will  be  required,  while  intermediate  sutures  of  horsehair  may  be  employed.  The 
apposition  should  be  very  exact,  and  it  is  often  necessary  to  insert  one  or  two  very 
fine  liorsehair  sutures  at  the  vermilion  border.  In  Fig.  412  the  dotted  lines  repre- 
sent the  extent  of  the  separation  of  the  lip  and  nostril  from  the  maxillary  bones, 
while  the  black  lines  indicate  the  distance  for  which  the  edges  of  the  fissure  should 
be  freshened,  with  the  incisions  through  the  lip  for  the  correction  of  the  deformity. 
In  these  more  difficult  operations,  there  is  very  apt  to  be  a  small  nick  remaining  in 
the  lip,  at  the  line  of  union,  which  will  have  to  be  closed  at  a  subsequent  operation. 
The  method  shown  in  Fig.  407  may  be  employed  to  correct  this  defect.  In  the 
operation  shown  in  Fig.  413,  the  freshening  should  extend  well  up  into  the  nostril 
on  either  side,  and  when  the  fiaps  have  been  made,  the  first  step  of  importance 
is  to  introduce  the  sutures  and  shape 
the  nostril  to  correspond  in  size  with 
its  fellow.  The  defect  in  the  lip  may 
then  be  closed,  as  in  the  preceding 
operation. 


Fig.  413. — Single  U-shaped  hareliiJ. 


Fig.  414. — Method  of  applying  ndlii"-ive  strips 
to  lessen  tension  on  the  sutures. 


When  by  reason  of  the  width  of  the  defect  as  shown  in  Fig.  413,  where  the 
harelip  is  U-shaiJed,  and  in  almost  all  cases  of  double  harelip  the  tension  on  the 
stitches  is  so  great  that  lateral  support  is  needed  during  the  process  of  repair.  To 
prevent  movements  in  the  lip,  and  to  relieve  the  tension,  the  method  illustrated  in 
Fig.  414  may  be  employed. 


324      THE   UVULA,   DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC. 

Double  Harelip. — The  operation  for  double  harelip  is  as  follows:  The  defect  in 
the  alveolar  arch  having  been  corrected,  the  edges  of  the  central  portion  of  the  defect 
are  pared,  as  indicated  by  the  black  line  in  Fig.  415.     The  edges  of  each  lateral 


Fig.  415. — (AltLT  Koenig.) 


Fig.   410.— (After  Koenig.) 


portion  of  the  lip  from  the  letter  a  upward  into  the  nostril  are  also  thoroughly  fresh- 
ened, while  the  lateral  incisions  from  a  to  6  are  made  to  extend  as  far  as  is  neces- 
sary to  correct  the  deformity.  The  condition  of  the  tissues  after  these  various 
freshenings  and  incisions  is  shown  in  Fig.  416.  The  sutures  are  then  inserted  first 
from  the  angle  between  the  two  arrows,  each  suture  passing  from  one  side  of  the 
lip  to  the  central  piece.  A  free  dissection  of  the  central  piece,  the  lips,  and  of 
both  nostrils  from  the  maxillae  is  also  indicated. 

In  certain  neglected  cases  of  double  harelip  in  adults,  where  there  is  marked 
deformity  of  the  nose,  in  order  to  correct  the  flattening  of  the  nostrils,  it  is  first 
necessary  to  fill  in  the  wide  gap  in  the  alveolar  arch.  The  operation  shown  in  Figs. 
396  and  417  has  been  devised  by  the  author  and  is  as  follows: 

On  account  of  the  hardening  of  the  bones,  it  will  be  found  impossible  to  carry 
the  alveolus  and  the  intermaxillary  bone  over  to  the  middle  line.  The  inner  sur- 
face of  the  intermaxillary  bone  and  the  opposing  margin  of  the  receding  alveolus 
of  the  opposite  side  are  freshened  with  the  knife  by  removing  the  mucous  covering. 
Between  two  of  the  teeth,  as  shown  in  the  dotted  line  (Fig.  396),  a  chisel  is  intro- 
duced and  the  bone  freely  divided  upward  between  these  two  teeth.  A  strong  wire 
or  heavy  silk  cord  is  now  inserted  into  this  fissure,  and  by  strong  traction  on  this 
the  superior  maxilla  is  fractured  and  carried  forward,  where  it  is  wired  as  shown  in 
Fig.  417.    The  fissure  in  this  method  is  transferred  from  the  alveolar  arch  in  front. 


Fig.  417. — Showing  the  method  of  advancement  by  which  the  anterior  alveolar  arch 
i.s  restored. 


back  within  the  mouth,  where  it  is  not  observed.  The  author  has  performed  this 
operation  in  two  instances  with  success.  Fortunately  the  conditions  which  make 
it  necessary  are  rare. 


THE  UVULA,   DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,    ETC.      325 

The  Toxgue  and  Buccal  Cavity 

Wounds  of  the  tongue  bleed  profuseh^,  especially  if  the  larger  vessels  along 
its  under  surface  are  divided.  The  arrest  of  hasniorrhage  is  easily  and  safely  accom- 
plished by  introducing  the  index-finger  back  over  the  dorsum  to  the  root  of  the 
tongue,  and  bringing  the  organ  forward  and  forcibly  compressing  it  against  the 
symphysis  menti.  The  tip  of  the  organ  should  be  turned  upward,  and  the  forceps 
applied  at  the  bleeding  points.  In  the  substance  of  the  tongue  the  vessels  are  also 
readily  secured  in  the  same  manner.  Should  any  difficulty  arise,  a  silk  tliread  may 
be  carried  around  the  bleeding  vessel  by  means  of  a  curved  needle,  or  it  may  be 
transfixed  with  a  tenaculum  and  the  thread  tied  around  the  hook.  The  operation 
of  tying  the  Unguals  or  external  carotids  is  elsewhere  given. 

Glossitis. — Inflammation  of  the  tongue  may  result  from  the  same  causes  and 
assume  all  the  phases  of  inflammation  common  to  the  soft  tissues  in  other  portions 
of  the  body.  It  may  be  acute  or  chronic,  ending  in  ulceration  or  hypertrophy.  The 
process  may  begin  superficially,  as  after  the  ingestion  of  some  irritating  substance, 
or  it  may  commence  in  the  deeper  portions  of  the  organ  as  a  diffuse  phlegmonous 
process.    In  some  instances  only  one  lateral  half  of  the  organ  is  involved. 

Treatment. — Inflammation  of  the  tongue  from  any  cause  should  be  closely 
watched,  on  account  of  the  danger  of  asphyxia  from  rapid  enlargement  of  this 
organ.  In  this  emergency  tracheotomy  should  be  performed.  If  aJ^scess  forms, 
incision  or  puncture  is  demanded.  Scarification  may  be  required  in  rapid  enlarge- 
ment from  engorgement  of  the  vessels. 

Hypertrophy  of  the  tongue  is  l^oth  congenital  and  acquired.  It-  may  exist  in 
adult  life,  although  it  is  in  general  a  condition  of  childhood.  The  enlargement 
is  due  to  hypertrophy  of  the  l}Tnphatic  plexuses  of  this  organ  and  to  a  general 
hyperplasia  of  the  connective-tissue  elements.  The  mus- 
cular substance  undergoes  granular  metamorphosis.  The 
cause  of  this  disease  is  not  understood.  The  organ  may 
become  so  large  that  it  protrudes  from  the  mouth,  pushes 
the  teeth  out  of  their  normal  position,  and  interferes  with 
deglutition  and  respiration  to  such  an  extent  that  its  par- 
tial or  complete  removal  becomes  necessary.     In  a  child  of 

twelve  years  with  congenital  maeroglossia  tremendous  hsem-  

orrhage  occurred  in  an  effort   at  removal.     Not  only  was      pj,,  41s  _A.uthor's  case 
the  operation  discontinued,  but  intravenous  injection  of  salt  of  maeroglossia. 

solution  was  necessary  to  prevent  a  fatal  issue.     Cystic  tu- 
mors of  the  tongue  may  be  mistaken  for  hypertrophy.     A  diagnosis  may  be  made 
by  exploration  with  a  good-sized  aspirator  needle. 

In  mild  cases  deligation  of  the  lingual  artery  of  one  or  both  sides  may  be  done, 
and  this  may  be  followed  by  excision  of  a  portion  of  the  organ.  The  tip  may  be 
amputated,  or  a  triangular  section  may  be  removed  from  the  central  portion,  the 
sides  being  brought  together  by  sutures.  Coagulation  of  the  contents  of  the  lymph 
and  blood  vessels  may  be  done  in  these  lesions  of  the  tongue  by  the  careful  em- 
ployment of  the  author's  hot-water  injection  method. 

Atrophy  is  a  rare  disease,  and  is  due  to  diminution  of  the  blood  supply,  or  to 
lesions  of  the  trophic  nerves  of  this  organ. 

Cystic  tumors  of  the  tongue  may  be  caused  by  closure  of  the  outlet  to  any 
portion  of  the  follicular  apparatus  (retention  cysts),  or  less  frequently  by  the 
lodgment  in  this  organ  of  a  parasite,  the  cysticercus. 

The  diagnosis  is  made  positive  by  exploration.  The  treatment  required  is  ex- 
cision of  the  sac  with  the  scissors,  or  the  less  bloody  operation  of  opening  it  with 
the  Paquelin  cautery,  burning  the  lining  membrane  thoroiighly,  and  packing  the 
cavity  with  gauze.  The  precaution  should  be  taken  to  make  the  packing  from  one 
piece  of  gauze,  and  of  securing  it  by  a  thread  attached  outside,  in  order  to  prevent 
its  accidental  escape  backward. 

Angeioma  of  the  tongue  is  rare.  When  present,  the  treatment  is  by  the  hot- 
water  injection  procedure. 

Aiscess  of  the  tongue  should  be  treated  by  incision  and  drainage. 


326      THE   UVULA,   DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC. 

Ulcers  of  the  tongue  apjjear  as  a  symptom  of  various  conditions.  They  occur 
in  syphilis  with  frequency.  They  may  occur  as  a  result  of  general  catarrh  of  the 
pharynx  and  mouth,  or  as  a  result  of  any  violence.  If  an  ulcer  exists  as  an  expres- 
sion of  a  dyscrasia,  the  treatment  must  be  chiefly  constitutional.  The  local  treat- 
ment consists  in  cleanliness  and  the  application  of  nitrate  of  silver,  or  other 
stimulating  remedies. 

The  tongue  is  at  times  the  seat  of  papilloma,  lipoma,  fibroma,  sarcoma,  and  one 
or  two  instances  of  enchondroma  in  this  organ  are  reported.  Epithelioma  is  not 
infrequent,  and  is  the  most  important  of  the  neoplasms  of  this  organ,  not  only  on 
account  of  its  greater  frequency,  but  also  on  account  of  its  grave  character  and 
the  necessity  of  arriving  at  an  early  diagnosis.  The  late  manifestations  of  syphilis 
(ulcers,  gumma,  fissures),  ulcers  of  tuberculosis,  and  some  specific  ulcers,  and 
papilloma,  may  be  mistaken  for  this  neoplasm. 

If  a  patient  has  a  syphilitic  history,  gumma  or  specific  ulcer  will  naturally  be 
suspected.  If  large  doses  of  potassium  iodide  and  mercury  be  administered  for 
two  or  three  weeks,  the  specific  ulcer  will  respond  to  this  remedy.  If  no  impression 
is  made  upon  it,  it  should  be  treated  as  malignant.  As  regards  all  other  suspicious 
sores  of  this  organ,  it  will  be  the  wiser  practice  to  treat  them  also  as  malignant 
growths,  for  it  is  a  well-recognized  fact  that  papillomatous,  tuberculous,  and  simple 
ulcers  of  the  tongue  (as  elsewhere),  chronic  in  character,  are  capable  of  transforma- 
tion into  epithelioma.  If  these  sores  are  removed  early  in  their  history,  no  muti- 
lation is  required,  the  operation  is  without  danger,  only  a  small  portion  of  the 
organ  need  be  sacrificed,  and  the  focus  of  disease  is  removed  before  its  malignant 
nature  is  declared  or  metastasis  occurs.  If  an  epitheliomatous  ulcer  exists,  its 
•character  may  be  determined  by  microscopical  examination,  as  given  by  Butlin.^ 
If  the  scraping  from  a  tuberculous,  syphilitic,  or  simple  ulcer  is  placed  in  a  drop 
of  water  on  a  slide,  pus-*  and  blood-corpuscles,  particles  of  food,  bacteria,  and  a 
few  normal  or  almost  normal  epithelial  cells  are  observed.  If  the  scraping  from 
an  epitheliomatous  ulcer  be  examined,  in  addition  to  the  above  will  be  seen  a  great 
number  of  abnormal  epithelia,  varying  in  size  and  shape,  some  flattened  scales, 
others  round  or  oval,  others  elongated,  with  caudate  prolongations.  The  cells  are 
generally  granular,  and  possess  from  two  to  three  or  more  nuclei,  much  larger  than 
the  normal  nuclei  of  these  cells.  In  some  instances  the  "  swallow's-nest "  arrange- 
ment may  be  observed. 

If  no  ulcer  is  present,  a  section  for  microscopical  examination  may  be  removed 
from  the  indurated  mass. 

Operation. — The  method  of  procedure  must  be  determined  by  the  extent  of  the 
organ  to  be  removed.  If  the  induration  is  confined  to  the  tip,  and  does  not  extend 
more  than  one  inch  behind  this  point,  the  line  of  section  should  be  at  or  near  the 
center  of  the  tongue.  It  should  always  be  well  away  from  the  disease.  An  inch 
from  the  nearest  induration  will  be  safer  than  to  allow  the  line  of  section  to  ap- 
proach the  neoplasm  in  order  to  save  more  of  the  tongue.  When  the  lateral  aspect 
of  the  anterior  half  is  involved,  the  line  of  section  need  not  pass  at  right  angles 
to  the  axis  of  the  organ,  but  may  curve  around  parallel  with  the  limit  of  induration 
at  a  sufiicient  distance  from  it.  In  this  way  the  anterior  portion  of  the  opposite 
half  may  be,  in  part,  preserved.  If  the  floor  of  the  mouth  is  infiltrated,  it  should 
he  dissected  from  its  attaclmnents  to  the  jaw,  and  the  diseased  part  removed  with 
the  tongue.  If  the  disease  extends  to  the  middle  of  the  tongue,  and  involves  its 
entire  width,  the  organ  shoidd  be  removed  at  its  base,  and  the  floor  of  the  mouth 
thoroughly  cleared  of  all  suspicious  tissue.  The  lymphatics  in  the  middle  line  below 
the  symphysis  menti,  in  the  submaxillary  region,  and  down  the  neck,  should  be 
examined  and  removed  if  metastasis  has  occurred. 

When  the  floor  of  the  mouth,  together  with  the  anterior  two  thirds  of  the 
organ,  are  involved,  and  metastasis  is  evident  in  the  deeper  lymphatics,  the  pro- 
priety of  surgical  interference  may  be  questioned.  A  cure  is  not  probable,  and  the 
operation  formidable  and  dangeroiis.  The  removal  of  the  ulcerating  portion  may 
be  done  as  a  palliative  measure. 

>  "Diseases  of  the  Tongue,"  Lea  Brothers  &  Co.,  Philadelphia,  1885. 


THE   UVULA,   DISEASES  OF   THE   PALATE,   HARELIP,   TONGUE,   ETC.      327 


Ether  and  morphia  combined  with  sequestration  should  be  employed.  It  is 
essential  for  the  teeth  to  be  held  widely  separated  by  the  gag,  and  the  lips  held 
out  of  the  way  by  flat,  blunt  retractors. 

\^Tien  the  tip  of  the  tongue  is  to  be  removed  the  eeraseur  may  be  employed.  It 
should  be  applied  well  posterior  to  the  ulcer.  Bleeding  from  the  stump  is  controlled 
by  forceps  and  silk  ligatures. 

When  a  more  extensive  operation  is  required,  the  following  method  will  be 
advisable : 

A  strong  silk  thread  should  be  passed  through  the  sound  tissues  of  the  tongue 
near  the  end  and  intrusted  to  an  assistant.  It  is  to  be  used  in  lifting  the  organ 
as  the  dissection  proceeds.  The  attachment  along  the  lower  jaw  should  first  be 
divided  with  the  scissors  or  knife  and  the  tissues  dissected  up  until  the  tongue  can 
be  lifted  freely  to  a  point  at  least  one  incli  behind  the  induration.  The  eeraseur 
loop  should  now  be  placed  around  the  organ  and  the  division  made.  Any  bleeding 
points  on  the  stump  can  be  readily  seized  with  the  long-nosed  narrow  forceps  and 
tied  with  silk  ligatures.  In  the  after-treatment  no  dressing  is  applied  to  the  wound 
in  the  mouth. 

If,  for  any  reason,  more  space  is  required  in  the  ablation  of  this  organ  than  can 
be  obtained  through  the  natural  orifice,  one  of  the  following  procedures  may  be 


1.  Gant's  incision  through  the  cheek,  from  the  angle  of  the  mouth  in  tlie  direc- 
tion of  the  lobe  of  the  ear  as  far  as  required  (Fig.  419,  a).  This  incision  gives  a 
full  view  of  the  lateral  aspect  of  the  tongue,  and  may  be  made  upon  both  sides 
when  the  disease  is  bilateral  and  extends 

beyond  the  middle  of  the  organ.  The 
edges  of  the  wound  are  afterwards  brought 
together  by  silk  sutures. 

2.  Kocher  has  lately  devised  an  oper- 
ation the  incision  in  which  is  shown  by 
the  line  b  d  e  c  (Fig.  419).  A  prelimi- 
nary tracheotomy  is  done  and  the  phar- 
ynx stuffed  with  a  plug  of  sterile  gauze 
to  which  a  string  is  attached.  The  ex- 
cision extends  along  the  anterior  border 
of  the  sterno-mastoid  muscle,  from  the 
level  of  the  lobule  of  the  ear  to  the  level 
of  the  hyoid  bone,  along  this  bone  to 
near  the  median  line,  and  thence  to  the 
symphysis  menti.  The  skin  and  platysma 
are  turned  up  on  the  Jaw,  the  lingual 
and  facial  arteries  and  veins  are  tied  as 
they  are  encountered,  all  enlarged  glands 
are  extirpated,  and  the  muscles  and  floor 
of  the  mouth  separated  along  the  attach- 
ments to  the  lower  jaw  to  any  required 
extent.  If  the  entire  tongue  is  to  be  removed,  the  opposite  lingual  is  also  tied. 
Through  this  opening  the  tongue  is  drawn  out,  dissected  from  its  anterior  and 
lateral  attachments,  surroimded  with  the  cautery  loop  and  divided,  or  cut  off  with 
the  eeraseur  or  scissors. 

If  necessary  to  a  thorough  command  of  the  operative  field,  these  two  incisions 
may  be  combined,  and  in  extreme  cases  of  metastasis  employed  upon  both  sides. 
Such  is  the  rapidity  of  metastasis  in  cancer  of  this  organ  that  the  widest  possible 
ablation  of  all  the  structures  in  the  floor  of  the  mouth  and  the  throat  should  be 
made. 

In  the  after-treatment  the  trachea  tube  is  left  in  place,  and  the  phar}Tix,  mouth, 
and  wound  filled  with  gauze.  The  wound  is  dressed  as  required,  and  liquid  nour- 
ishment given  at  each  change  of  the  dressing.  Colon  alimentation  is  an  important 
adjuvant. 

The  operations  in  which  the  organ  is  removed  through  the  mouth  are  simpler, 


-Incision  of  Gant  and  Koche 
(After  ButUn.) 


328      THE   UVULA,   DISEASES   OF  THE   PALATE,   HARELIP,   TONGUE,   ETC. 

and  require  mucli  less  time  in  execution,  but  in  general  unless  the  disease  is  very 
recent  (four  to  six  weeks)  the  radical  procedures  give  a  better  assurance  of  success. 

The  after-treatment  consists  in  rinsing  the  mouth  at  frequent  intervals  with  a 
warm  solution  of  permanganate  of  potassa  (gr.  ss.  to  gj),  anodynes  to  relieve  pain, 
and  generous  liquid  diet. 

Ranula. — This  name  is  applied  to  certain  tumors,  cystic  in  character,  which  are 
situated  immediately  beneath  the  anterior  and  lateral  portions  of  the  tongue.  Ean- 
ula  is  usually  acquired,  although  it  may  be  congenital.  The  tumor  is  almost  always 
single;  occasionally  there  is  one  on  either  side  of  the  organ.  Commencing  as  a 
result  of  obstruction  to  the  outlet  of  one  of  the  subdivisions  of  the  sublingual  gland 
(rarel}^  as  a  result  of  occlusion  to  one  of  the  terminal  ducts),  it  may  grow,  when 
left  undisturbed,  to  great  size,  crowding  the  tongue  out  of  its  position,  rising  above 
the  level  of  the  teeth,  and  protruding  through  the  muscles  of  the  chin  until  it 
appears  beneath  the  skin  above  the  hyoid  bone. 

The  treatment  is  to  evacuate  the  contents  and  dissect  out  the  sac  or  cause  its 
obliteration  by  inflammatory  adhesion.  The  Paquelin  cautery  is  the  best  instru- 
ment to  employ  in  removal.  Etlierize  the  patient,  introduce  the  gag,  lift  the  tongue 
upward  with  the  forceps,  j)rotect  the  lips  and  teeth  by  means  of  flat  retractors,  seize 
the  wall  of  the  cyst  with  a  mouse-tooth  forceps,  and  with  the  platinum  knife  at  a 
red  heat  dissect  away  the  anterior  wall.  After  the  fluid  escapes,  dilate  the  cavity, 
and  make  a  thorough  digital  exploration  of  the  sac.  The  cautery  knife  should 
now  be  carried  slowly  back  to  the  deepest  j^ortions,  searing  all  sides  of  the  cyst 
wall.  The  wound  should  be  well  packed  with  a  single  ribbon  of  gauze.  The  after- 
treatment  consists  in  changing  the  packing  every  twenty-four  to  forty-eight  hours, 
and  at  each  dressing  irrigating  the  cavity  with  1-2000  sublimate  solution. 

If  the  Paquelin  thermo-cautery  is  not  convenient,  seize  the  cyst  wall  with  the 
forceps  and  dissect  it  out  "with  curved,  blunt  scissors,  and  apply  pure  carbolic  acid 
freely  neutralizing  the  excess  with  alcohol.  Pack  the  wound  firmly. with  gauze,  as 
above.    HEPmorrhage  may  be  controlled  as  directed  in  wounds  of  the  tongue. 

Tongue-tie. — When  the  frsenum  extends  an  unusual  distance  toward  the  tip 
of  the- tongue,  or  is  so  narrow  that  it  checks  the  free  movements  of  this  organ,  it 
should  be  divided  in  the  following-  manner :  Seize  the  tip  of  the  tongue  with  a 
dry  towel,  carry  it  iipward  so  as  to  put  the  bridle  on  the  stretch,  and,  with  a  curved 
scissors,  divide  the  frasnum  from  one  eighth  to  one  quarter  of  an  inch  nearer  to 
the  floor  of  the  mouth  than  to  the  surface  of  the  tongue.  This  precaution  is  neces- 
sary to  avoid  wounding  the  ranine  vessels.  The  gag  may  be  used  if  required. 
This  procedure  should  be  made  painless  by  cocaine  infiltration.  The  strip  of  raw 
surface  left  by  the  cutting  should  be  closed  over  by  chromicized  catgut  sutures  to 
prevent  recurrence  from  adhesions. 

A  congenital  defect,  very  rarely  observed,  is  tlie  adhesion  of  the  tongue  to  the 
floor  of  the  mouth.  The  adhesions  should  be  broken  up  at  birth  and  the  raw  sur- 
face covered  as  just  described. 

Equally  rare  is  the  bifid  or  snake  tongue,  which  results  from  arrest  of  develop- 
ment or  failure  of  union  of  the  two  halves  from  which  this  organ  is  formed.  The 
edges  should  be  f)ared,  and  the  two  halves  united  in  the  median  line  by  sutures. 

Tonsils. — Acute  tonsillitis  is  of  very  frequent  occurrence,  causing,  in  a  varying 
degree,  pain,  difficulty  of  deglutition,  and  interference  with  p)honation,  deglutition, 
and  respiration. 

The  pathology  of  this  affection  consists  in  dilatation  of  the  blood  and  IjTuph 
vessels,  emigration  of  leucocytes,  and  proliferation  of  the  connective  tissue  and 
other  cell  elements  of  the  tonsil.  The  gland  rapidly  enlarges,  producing  great 
tension  of  the  jDillars  of  the  fauces,  and  projects  toward  the  median  line,  at  times 
filling  the  pharynx  and  crowding  the  velum  upward  and  backward. 

Acute  tonsillitis  may  end  in  resolution,  the  gland  rapidly  diminishing  to  its 
normal  size,  or  in  ulceration  or  suppuration  (abscess),  or  the  acute  process  may 
subside  into  a  chronic  form  of  inflammation,  which  induces  permanent  hypertrophy 
of  the  organ. 

The  local  treatment  of  acute  tonsillitis  consists  in  the  aijplieation  of  hot  water  as 
^  gargle,  and  scariflcation  of  these  organs  when  the  tension  is  sufficient  to  produce 


THE   UVULA,    DISEASES   OF   THE   PALATE,   HARELIP,   TONGUE,   ETC.      329 

great  pain.  The  internal  administration  of  aconite  tincture  and  quinine  is  highly 
recommended. 

Abscess  of  the  tonsil  sliould  be  opened  as  soon  as  its  presence  is  detected.  The 
discharge  of  pus  always  brings  great  relief.  If  the  symptoms  lead  to  the  suspicion 
of  pus,  exploration  with  the  hypodermic  aspirator  needle  should  be  made  to  deter- 
mine the  diagnosis.  The  internal  carotid  artery  and  jugular  vein  are  well  back 
from  the  tonsil,  on  a  level  with  the  posterior  wall  of  the  pharynx. 

The  object  in  operating  early  is  to  prevent  oedema  of  the  glottis,  which  may 
occur  when  the  abscess  is  large  or  situated  behind  the  body  of  the  tonsil.  A  more 
remote  danger  is  rupture  of  the  abscess  during  sleep,  and  escape  of  the  contents 
into  the  larynx. 

Chronic  hypertrophy  of  the  tonsils  should  be  treated  by  partial  or  complete 
excision.  The  presence  of  these,  enlarged  organs  forces  the  patient  to  breathe 
through  the  mouth,  a  habit  which  often  induces  a  catarrhal  condition  of  the  mucous 
membrane  lining  the  respiratory  tract.  The  constant  presence  of  infectious  organ- 
isms in  chronic  hypertrophy  of  these  organs  is  a  source  of  -grave  danger.  Glandular 
enlargements  in  the  neck  (tuberculosis),  diphtheria,  and  other  infections  are  apt 
to  result,  while  nasopharyngeal  catarrh  and  Eustachian-tube  involvement  and 
ostitis  media  are  natural  sequences.  The  follicles  of  the  tonsils  discharge  a  dirty, 
cheesy  secretion,  which  at  times  becomes  retained  in  the  gland  and  undergoes  cal- 
cification. Calculi  one  fourth  of  an  inch  in  diameter  have  been  removed  from  this 
organ. 

Tonsillotomy. — Excision  of  the  tonsils  is  an  operation  practically  free  from  dan- 
ger. In  children  who  cannot  control  themselves,  auEesthesia  should  be  used,  the 
gag  introduced,  and  the  tongue  depressed  by  an  assistant.  The  operator  seizes  the 
exposed  portion  of  the  organ  with  a  long  mouse-tooth  forceps  or  a  tenaculum,  pulls 
it  slightly  toward  the  median  line,  and  with  a  long-handled  pair  of  scissors,  crirved 
on  the  flat,  clips  off  from  one  tliird  to  one  half  the  tonsil.  A  sponge,  fixed  in  a 
holder,  dipped  in  ice  water  and  pressed  on  to  the  bleeding  surface,  will  arrest  the 
haemorrhage. 

In  adidts  local  anassthesia  may  be  insured  by  cocaine  hydrochlorate,  and  the 
operation  joerformed  as  above,  with  much  greater  facilit}',  since  the  intelligent 
cooperation  of  the  patient  is  of  great  value.     If  the  long  scissors  cannot  be  had. 


Fig.  420. — Mackenzie's  tonsillotome. 


a  long,  curved,  probe-pointed  bistoury  may  be  used  instead.  The  tonsil  is  lifted 
from  its  bed  by  a  tenaculum,  and  the  knife  carried  through  as  above. 

Various  tonsillotomes  have  been  introduced,  and  for  some  cases  are  very  useful, 
but  for  simplicity  and  general  application  the  instruments  above  selected  will  an- 
swer all  purposes.  Among  the  best  of  the  tonsillotomes  is  that  of  Mackenzie  (Fig. 
420),  and  Tiemaun's  instrument  (Fig.  421). 

The  tonsil  is  also  occasionally  the  seat  of  malignant  neoplasms,  as  sarcoma  and 
carcinoma,  while  cystic  tumors,  fibroma,  and  lymphoma  are  among  the  benign 
new  formations  which  attack  tliis  gland.  They  require  early  and  thorough  excision 
in  all  eases. 


330      THE   UVULA,   DISEASES   OF  THE  PALATE,   HARELIP,   TONGUE,   ETC. 

When  this  organ  is  tlie  seat  of  inoperable  sarcoma  the  inoculations  with  the 
toxines  of  erysipelas  or  the  mixed  products  of  the  bacillus  prodigiosus  and  Fehlei- 
sen's  coccus  are  advised. 

With  these  procedures  in  all  cases  of  inoperable  tumors  of  the  nasopharyngeal 
and  tonsillar  regions.  Professor  Dawbarn's  complete  removal  of  the  external  carotid 


artery  and  its  branches  on  both  sides  of  the  neck  will  by  starvation  greatly  lessen 
the  dangers  of  further  growth  and  in  some  instances  cause  shrinkage  and  disap- 
pearance of  the  neoplasm. 


CHAPTEE    XYII 

THE     XECK ■^VOU^"T)S,     IXFECTIOX,     TmOES,     GOITEE,     LESIOXS     OF     THE     LAETX5, 

TRACHEA    AXD    (ESOPHAGUS,    GASTEOSTOIIT 

Wounds. — Wounds  of  the  neck  mav  prove  rapidly  fatal  from  hjemorrhage  in- 
ducing SATicope;  from  ha?morrhage  into  the  trachea,  causing  fatal  asphyxia:  from 
the  entrance  of  air  into  tlie  veins ;  or  from  injury  to  the  cord,  at  or  near  the  me- 
dulla. Death  from  sepsis  may  occur  as  a  more  or  less  remote  sequence  of  a  wound 
in  this  region. 

Treatment. — The  immediate  indications  are  to  arrest  haemorrhage  at  once,  and 
prevent  asphyxia,  or  the  admission  of  air  into  the  veins.  Hsemorrhage  should  be 
controlled  by  presstire  directly  in  the  wound,  until  the  injured  vessels  can  be 
secured  by  the  ligature.  The  entrance  of  air  into  the  veins  must  be  carefully 
prevented,  by  constant  pressure  on  the  cardiac  side  of  the  lesion,  until  the  forceps 
have  been  successfully  applied  to  the  bleeding  point. 

When  the  woimd  is  incised  or  lacerated,  and  is  above  the  hyoid  bone  and  has 
severed  the  hyoid  muscles,  in  addition  to  the  prevention  of  hsmorrliage  into  the 
lar^TLX  the  tongue  must  be  drawn  forward,  for  when  these  muscles  are  divided 
it  falls  back  upon  the  glottis,  and  may  occlude  the  larynx.  If  the  tracliea  is  opened, 
the  edges  of  the  wound  should  be  held  apart  with  tenacula,  the  head  dropped  over 
the  end  of  a  table,  any  clots  removed,  and  artificial  respiration  practiced  by  Syl- 
vester's method.  When  the  pneumogastric,  h}-poglossal,  or  other  important  nerves 
have  been  divided,  the  ends  should  be  brought  together  by  stiture.  It  is  also  neces- 
sary to  unite  the  ends  of  divided  muscles.  An  incised  wound  of  the  cesophagus 
should  be  closed  immediately.  If  infection  has  occurred  it  should  be  left  open  and 
kept  thoroughly  cleansed.  The  patient  should  he  nourished  by  colon  alimentation. 
Lacerated  wounds  of  this  tube  should  be  allowed  to  close  by  granulation.  DilSeultv' 
in  deglutition  follows  severe  wounds  of  the  throat,  not  infrequently  necessitating 
the  introduction  of  liquid  food  through  the  oesophageal  tube,  or  feeding  by  the 
rectum. 

Punctured  wounds  of  the  neck  should  be  dressed  antiseptically,  and  compression 
employed  to  arrest  hemorrhage.  If  this  does  not  succeed,  the  ligature  should  be 
applied. 

G-unshot  wounds  should  be  treated  in  practically  the  same  manner.  Missiles 
of  small  caliber  deeply  lodged  should  be  left  alone,  since  they  usually  become  en- 
capsuled  and  remain  harmless.  When  superficial  and  readily  detected,  they  should 
be  extracted  by  the  forceps.  In  the  effort  to  locate  a  bullet  the  X-ray  should  be 
the  chief  reliance.  Unless  infection  has  taken  place,  probing  is  rarely  if  ever 
indicated.  Gunshot  wounds  traversing  the  outer  lateral  and  superficial  posterior 
regions  of  the  neck  are  not,  as  a  rule,  dangerotts.  If  the  vertebral  coltmm  is  in- 
volved, the  prognosis  becomes  grave.  A  missile  traversing  the  tissues  of  the  neck 
laterally,  and  in  front  of  the  vertebra]  column,  is  apt  to  inflict  fatal  injury. 

Alscess. — Abscess  of  the  neck  occurs  most  freqtiently  in  children.  It  is  met 
with  in  infective  adenitis,  or  periadenitis,  tonsillitis,  and  in  caries  of  the_  upper 
cervical  vertebrse,  or  base  of  the  skull  (retro-pharrageal  abscess).  Collections  of 
pus  in  the  upper  cervical  regions,  and  in  the  superficial  portions  of  the  root  of 
the  neck,  tend  to  become  encapsuled,  or  may  open  ultimately  through  the  integu- 
ment. Eetro-pharyngeal  abscess,  if  left  alone,  not  infrequently  travels  down-«-ard 
along  the  deep'  fascia  of  the  neck,  and  may  open  into  the  mediastintun. 

331 


332  THE   NECK 

The  diagnosis  of  abscess  in  the  neck,  from  the  various  tumors  which  are  found 
in  this  region,  deiDends  upon  the  febrile  movement  present  in  abscess,  the  acute 
and  persistent  character  of  the  pain,  and  fluctuation.  The  value  of  exploration, 
with  an  aspirator  needle  large  enough  to  carry  pus,  should  not  be  lost  sight  of  in 
the  effort  to  arrive  at  a  positive  diagnosis. 

The  treatment  is  evacuation,  either  by  the  method  of  aspiration  and  hyperdis- 
tention  already  given,  or  by  puncture  or  incision,  and  free  drainage.  When  the 
abscess  is  situated  in  a  portion  of  the  neck  rich  in  vessels,  it  should  be  opened  by 
cutting  carefuUj^  down  upon  it,  so  that  any  hEemorrhage  encountered  may  be  imme- 
diately and  readily  controlled.  If  a  puncture  is  determined  upon,  the  knife  should 
be  introduced  in  the  f)art  farthest  from  the  vessels,  and  along  the  aspirator  or 
exploring  needle  as  a  guide.  As  soon  as  the  sac  is  entered  by  the  instrument  it  is 
withdrawn  and  a  dull-pointed  dressing  forceps,  tightly  closed,  is  carried  into  the 
abscess,  when,  by  forcible  separation  of  the  jaws,  the  puncture  is  enlarged. 

Tlie  finger  may  now  be  introduced,  or,  if  this  cannot  be  done,  the  forceps  or 
probe  will  indicate  the  size  and  most  dependent  portion  of  the  sac.  If  the  first 
opening  has  not  been  made  at  the  lowest  part  of  the  abscess,  or  is  not  so  situated 
that  thorough  drainage  is  secured,  it  should  be  enlarged  so  as  to  extend  this  far, 
or  a  counter-opening  made  by  boring  through  with  the  forceps  rmtil  the  skin  is 
distended  over  the  point  of  the  instrument,  when  it  can  be  safely  incised.  Drain- 
age should  be  maintained,  and  the  cavity  irrigated  with  1-3000  sublimate  solution. 

The  diagnosis  of  retro-pharyngeal  abscess  depends  upon  the  following  sjanp- 
toms :  Pain,  a  feeling  of  soreness  and  stiffness  in  the  neck,  swelling,  with  protrusion 
of  the  posterior  wall  of  the  pharjirx  if  the  disease  is  high  up,  interference  with 
deglutition  and  respiration.  In  the  earlier  stages  all  of  these  symptoms  will  not 
be  present,  but  as  soon  as  this  dangerous  condition  is  suspected  an  effort  should  be 
made  to  locate  the  abscess  Y>j  palpation  and  aspiration. 

In  evacuating  the  pus  an  incision  should  be  made  in  the  pharynx,  as  near  the 
median  line  as  possilile.  When  a  large  quantity  of  fluid  is  present  the  head  should 
be  inclined  dowTiward  as  the  incision  is  made,  so  tliat  the  contents  of  the  abscess 
may  not  gravitate  into  the  lar3Tix.  This  danger  may  be  obviated  by  partially  empty- 
ing the  sac  by  the  aspirator  before  the  incision  is  made.  Wlien  the  sac  extends 
low  down  the  neck  it  should  be  entered  and  drained  from  below.  Deep  retro- 
pharyngeal abscess  may  he  reached,  as  a  rule,  by  the  incision  and  dissection  laid 
down  in  the  operation  of  wsophagotomy. 

Phlegmon  of  the  neck  demands  free  incision  in  all  cases,  when  such  incision 
does  not  encroach  upon  the  important  organs  of  this  region. 

Infection  of  the  superficial  cervical  glands  is  easily  recognized,  and  the  treat- 
ment by  incision  and  drainage  comparatively  easy.  Involvement  of  the  deeper 
lymphatics  or  of  the  glands  in  general  is  often  rapidly  overwhelming.  In  indi- 
viduals of  low  resistance  the  infecting  organisms  entering  from  the  buccal  or  naso- 
phar3'ngeal  cavities  rapidly  pass  from  the  gland  substance  and  carry  widespread 
infection  into  the  tissues  of  the  neck.     (Ludwig's  Angina.) 

The  prognosis  is  unfavorable.  The  treatment  demands  multiple  incision  to 
relieve  tension  and  the  active  improvement  of  the  patient's  nutrition. 

Tumors  of  the  Neclc — Solid  and  Cystic — Lymphoma. — Pathological  changes  in 
the  lymphatics  of  the  neck  account  for  the  large  majority  of  swellings  in  tliis  region. 
Ljrmphoma  of  the  neck  may  be  solid  or  cystic,  benign  or  malignant. 

Tumors  of  the  cervical  glands  may  comprise  simple  l^anphoma,  the  result  of 
hypertrophy  and  hyperplasia;  tubercular  lymphoma,  lympho-sarcoma,  and  lym- 
phangiectasis. 

Tubercular  lymphoma  occurs  most  frequently  in  the  submaxillary  and  upper 
carotid  triangle,  and  next  in  order  of  freqiiency  along  the  line  of  the  great  vessels 
beneath  the  mastoideus,  and  lastly  in  the  subclavian  region.  In  some  instances 
these  tumors  attain  enormous  proportions,  filling  in  the  neck  to  the  level  of  the 
lower  jaw  and  clavicle,  and,  if  not  removed,  produce  annoying  pressure  upon  the 
respiratory  apparatus  or  the  oesophagus.  They  should  be  removed  by  operation  at 
the  earliest  possible  moment  if  a  cure  is  to  be  effected.  When  left  until  they  are 
of  considerable  size  and  numerous  the  prognosis,  even  after  thorough  operation,  is 


THE   NECK  333 

unfavorable,  since  the  infection  in  these  cases  will  have  passed  already  into  the 
mediastinal  and  bronchial  glands. 

Excision  is  not  indicated  in  the  rare  cases  of  lymphoma  of  the  neck  Icnown  as 
Billroth's  disease.  The  local  injection  and  internal  administration  of  Fowler's 
solution,  the  details  of  which  are  given  elsewhere,  is  highly  recommended.  (See 
Sarcoma.) 

Fatty  tumors  are  apt  to  occur  upon  the  posterior  aspect  of  the  neck,  and  occa- 
sionally in  the  clavicular  region.  They  are  comparatively  rare  in  the  anterior  and 
upper  triangles. 

Cystic  Tumors. — Cysts  of  the  neck  are  congenital  and  acquired. 

Congenital  cysts  are  rare.  The  form  most  frequently  observed  is  that  already 
mentioned  as  a  dilatation  and  hj'pertrophy  of  the  lymphatic  vessels  ( Ijanphangiee- 
tasis).  They  are  usually  multilocular,  and  may  extend  deeply  and,  at  times,  assume 
enormous  proportions. 

Occasionally  the  carotid  body,  a  small  glandlike  organ,  made  up  of  small  lobular 
collections  of  cells  ^  without  definite  arrangement,  enclosed  in  a  fibrous  capsule 
and  located  at  or  near  the  angle  of  bifurcation  of  the  common  carotid  artery  under- 
goes hypertrophy.  It  Ijecomes  formidable  by  reason  of  the  involvement  in  its  sub- 
stance of  the  carotid  and  its  primitive  divisions.  It  grows  slowly,  and  is  not  jjain- 
ful  until  it  causes  pressure  upon  contiguous  nerves. 

The  diagnosis  depends  chiefly  upon  the  location  of  the  neoplasm,  which  is 
movable  laterall}'  but  not  verticallj^.  It  is  lifted  by  the  jmlsation  in  the  artery,  but 
is  of  itself  non-expansile. 

Branchial  cysts  and  fistula;  are  congenital  and  result  from  the  failure  of  closure 
in  a  portion  of  one  or  more  of  the  branchial  clefts,  most  commonly  the  third,  occa- 
sionally the  fourth.^  These  fistulas  traverse  the  tissues  of  the  neck,  open  into  the 
pharynx,  and  becoming  infected  discharge  externally  a  varying  quantity  of  slightly 
purulent  fluid. 

They  may  be  cured  by  extirpation,  but  it  is  often  difficult  to  trace  the  tract  to 
its  deeper  opening.  The  careful  injection  of  very  hot  water  would  tend  to  destroy 
the  lining  secretory  membrane.  The  author  has  employed  this  method  successfully 
in  old  sinuses  elsewhere  which  were  otherwise  incurable. 

The  Thyroid  Body — Goitee 

The  abnormal  conditions  of  the  thyroid  body  which  bring  this  organ  within 
the  province  of  surgery  are  (1)  traumatism,  (3)  infection,  (3)  hypertrophy,  (-f) 
neoplasm,  (5)  functional  disturbance. 

Normally  the  thyroid  is  richly  supplied  with  blood  vessels,  and  in  any  form 
of  hypertrophy  and  in  almost  all  functional  disturbances  its  vascularity  is  in- 
creased. In  most  of  these  pathological  changes  the  plexuses  of  veins  are  not  only 
more  distended  and  tortuous,  but  their  walls  become  abnormally  friable.  In  all 
operative  procedures  this  peculiarity  of  the  thyroid  should  be  borne  in  mind  in 
the  selection  of  the  anaesthetic.  Ether  or  chloroform  narcosis  always  increases  the 
engorgement  of  the  veins  of  the  neck,  and  with  these  the  vessels  become  more 
than  ordinarily  turgid,  and  necessitating  clamping  and  dividing  between  the  for- 
ceps, with  immediate  application  of  the  ligature. 

In  order  to  lessen  tliis  blood  pressure,  general  narcosis  should  as  far  as  possible 
be  avoided,  relying,  as  demonstrated  by  Kocher  in  several  thousand  operations, 
upon  the  anfesthetic  effect  of  cocaine  or  quinia  and  urea  infiltration  combined  with 
the  hypodermic  use  of  morphia.  It  may  be  advisable  in  certain  cases  to  add 
adrenalin  (1-1000  or  1-2000)  to  the  cocaine  infiltration,  and  should  temporary 
general  narcosis  become  necessary  nitrous-oxide  gas  with  oxygen  or  the  smallest 
possible  quantity  of  chloroform  or  ether  with  oxygen  should  be  employed.  To 
these  precautionary  measures  may  be  added  the  elevation  of  the  patient's  head 

1  J.  Chalmers  Da  Costa,  "Annals  of  Surgery,"  1906;  W.  W.  Keen  and  J.  Funke  in  the  "Journal 
of  the  American  Medical  Association,"  vol.  xlvii;  report  twenty-nine  cases  of  this  body.  It  was 
first  described  by  Marchand  in  1S91. 

^  M.  J.  Cheever,  "Annals  of  Surgery,"  June,  1906. 


334  THE   NECK 

(reversed  Trendelenburg)  or  Dawbarn's  sequestration  method,  which  will  be  found 
a  most  valuable  adjunct  in  diminishing  blood  pressure  in  the  operative  field. 

Wounds  of  the  thyroid  may  be  contused,  incised,  punctured,  or  gunshot.  Con- 
tused wounds  rarely  cause  injury  sufficient  to  demand  surgical  intervention.  Should 
hematoma  occur  it  should  be  left  undisturbed  unless  compression  and  continued 
bleeding  necessitates  incision,  turning  out  the  clot  and  the  ligature.  Incised 
wounds  are  mostly  suicidal,  and  require  the  immediate  arrest  of  hemorrhage,  with 
disinfection.  Infection  of  the  thyroid  body  occurs  occasionally  in  connection  with 
general  infection  of  the  anterior  portion  of  the  neck,  in  rare  instances  by  metas- 
tasis in  typhoid  fever  and  other  general  septic  processes.  The  indications  are  to 
drain  at  once  any  septic  focus.  The  thyroid  is  richly  supplied  with  lymphatics 
which  act  as  ducts  to  its  secretory  apparatus  and  are  capable  of  rapidly  conveying 
toxic  material  into  the  circulation.  By  reason  of  the  peculiar  arrangement  of  the 
capsule  which  surrounds  the  oesophagus  and  trachea,  a  sudden  swelling  of  this 
organ  may  cause  dangerous  comjjression.  Closely  related  to  the  four  thyroid  arteries 
which  supply  this  body  are  some  important  structures,  namely,  the  recurrent 
laryngeal  nerves  and  the  parathyroid  bodies.  The  recurrent  laryngeal  nerve  on 
the  right  side  is  in  close  relation  to  the  inferior  thyroid  artery,  while  on  the  left 
it  is  somewhat  more  deeply  seated. 

The  parathyroid  bodies,  usually  four  in  number,  are  situated  posteriorly  ujjon 
or  just  within  the  capsule  in  close  relation  to  the  thyroid  arteries  as  they  break 
up  into  smaller  branches  to  penetrate  the  gland  substance  (Fig.  422).  It  is  of  very 
great  importance  that  these  bodies  be  not  only  not  removed,  but  that  they  be  not 
roughly  handled  or  damaged  by  surgical  traumatism.  By  keeping  well  within  the 
capsule  at  the  lower  and  upper  posterior  portions  of  this  organ  they  may  be  avoided. 
The  vipper  one  is  usually  at  the  side  of  the  larynx  and  oesophagus,  while  the  lower 
one  may  be  seen  just  beloiv  the  inferior  thyroid  artery.  They  are,  however,  subject 
to  variation  in  number  as  well  as  location,  and  while  most  frequently  situated 
behind  the  capsule,  they  may  be  enclosed  within  it,  in  which  ease  even  with 
proper  care  they  may  not  escape  removal  or  injury.  According  to  S.  P.  Beebe, 
the  parathyroids  and  the  thyroid  body  are  different  in  their  histological  struc- 
ture, and  entirely  different  in  their  functions.  Complete  removal  of  the  thyroid 
causes  cachexia,  which  may  in  large  part  be  relieved  by  the  administration  of 
th3Toid  substance,  while  removal  of  the  parathyroids,  if  complete,  is  followed  by 
acute  fatal  tetany.^  In  sixteen  cases  examined  by  MacCallum  the  cells  of  all  varie- 
ties found  in  the  normal  gland  were  seen  in  these  in  the  usual  proportions,  show- 
ing that  they  were  not  changed  by  the  diseased  condition  of  the  thyroid  body. 

Hypertrophies  of  the  thyroid  may  be  clinically  divided  into  simple,  solid,  semi- 
solid, and  cystic.  (The  variety  knoATi  as  exophthalmic  goitre  is  not  included  here, 
but  will  be  considered  with  functional  lesions  of  this  organ.) 

Simple  goitre  is  a  form  which  occurs  in  young  adults,  almost  always  in  fe- 
males, coming  on  usually  about  the  sixteenth  or  eighteenth  year,  seemingly  asso- 
ciated with  the  menstrtual  function,  enlarging  at  times  and  diminishing  at  others, 
and  continuing  on  in  this  way  for  five  to  ten  years,  when  the  swelling  disap- 
pears. In  a  certain  proportion  of  these  cases,  however,  the  enlargement  remains 
more  or  less  permanent,  and  may  ultimately  require  surgical  intervention.  This 
form  occurs  also  during  pregnancy  in  a  small  proportion  of  parturient  women. 
Under  proper  dietetic  and  medical  treatment  these  simple  hypertrophies  may  be 
held  in  abeyance  or  cured. 

In  the  solid  form  of  goitre  there  is  a  proliferation  of  the  connective-tissue 
stroma  at  the  expense  of  the  cell  elements.  It  grows  comparatively  slowly,  but 
as  the  capsule  becomes  tense  the  symptoms  of  compression  upon  the  trachea  and 
recurrent  laryngeals  are  more  marked  than  in  the  larger  and  softer  tumors.  As 
the  glandular  cell  elements  become  atrophied  there  are  apt  to  develop  symptoms  of 
hypothjToidism. 

'  Transactions  of  the  American  Medical  Association,  1907.  According  to  E.  H.  Poole  ("An- 
nals of  Surgery,"  October,  1907),  each  parathyroid  consists  of  a  mass  of  cells  and  is  completely 
invested  with  a  thin  fibrous  capsule  beneath  which  a  fine  anastomosis  may  be  seen.  In  size 
they  vary  from  3  to  15  mm.  and  in  color  from  brown-red  to  reddish-yellow. 


THE  NECK 


335 


In  the  semi-solid  goitre  there  are  isolated  foci  of  connective-tissue  hyperplasia 
with  neighboring  cystic  expansions  of  the  normal  elements,  which  contain  a 
colloid  material  in  varying  quantities. 

In  cystic  goitre  proper  there  are,  as  a  rule,  from  one  to  three  large  cysts,  at 
times  the  whole  gland  being  occiipied  by  a  single  cavity,  the  liquid  contents  of 
which  are  considerably  changed  as  compared  to  the  colloid  material  of  the  semi- 
solid  varietv".      The  fluid,   when  withdrawn  by   aspiration   for    examination   and 


Fig.  422. — The  posterior  wall  of  the  oesophagus,  showing;  the  relations  of  the  parathyroid  bodies  to 
the  thyroids.  The  posterior  capsule  of  each  th>Toid  has  been  removed,  showing  the  two  bean- 
shaped  parathvroids  of  each  thyroid.  (After  W.  S.  Halsted  and  H.  M.  Evans,  "Annals  of 
Surgery,"  October,  1907.) 

diagnosis,  is  dark  coffee-colored,  and  shows  under  the  microscope  crenated,  red- 
blood  cells  in  large  numbers,  together  with  leucocytes  and  the  very  large  compound 
granular  corpuscles  of  Gliige.  and  not  infrequently  eholesterin  crystals. 

Neoplasms  of  the  th}Toid  body  are  comparatively  rare,  those  usually  met  with 
being  sarcoma  and  carcinoma. 

Sarcoma  and  carcinoma  of  this  organ  are  hard,  solid  tumors  of  rapid  develop- 
ment, steadily  increasing  in  size,  and  in  their  growth  binding  the  invaded  organ 
to  the  integument,  muscles,  and  fascia  of  the  neck.  Abscess  would  give  a  pre- 
.vious  history  of  inflammation,  pain,  and  febrile  movement.  Aneurism  of  the 
carotid  appears  usually  to  the  outer  side  of  the  thjToid  region,  and  presents  the 


336  THE   NECK 

sjanptoms  of  expansion  with  tlie  heart's  systole,  tlie  aneurismal  thrill  and  murmur, 
all  of  which  s_ymptoms  disappear  after  pressure  iipon  the  artery  on  the  cardiac 
side  of  the  tumor.  In  the  earlier  history  of  thyroid  tumor  it  is  movable  with  the 
trachea  in  the  act  of  deglutition. 

Tubercular  Ij'mphomata  are  recognized  b}'  their  anatomical  locations,  and  by 
their  slow  process  of  development.  In  many  instances  these  timiors  of  the  glands 
remain  quiet  for  a  variable  period,  when  pyogenic  infection  occurs,  with  the  for- 
mation of  acute  abscess.  They  are  found  most  frequently  along  the  lower  border 
of  the  inferior  maxilla  in  the  lower  carotid  region,  along  the  under  surface  and 
posterior  border  of  the  sterno-mastoid  muscle,  and  in  the  subclavian  triangle. 

Metastatic  lymphomata  secondary  to  epithelioma  or  other  malignant  disease 
of  the  face,  will  be  recognized  by  the  historj'  of  the  case.  Lympho-sarcoma  of  the 
neck  is,  in  its  earlier  stages  of  development,  with  difficulty  difEerentiated  from 
simple  adenoma.  It  grows,  however,  with  much  greater  rapidity,  and,  by  its 
tendency  to  become  fixed  to  the  surrounding  tissue,  suggests  its  malignant  nature. 
It  is  most  usually  located  along  or  beneath  the  sterno-mastoid  muscle. 

Functional  Disturbances. — There  is  a  condition  of  abnormal  increase  in  thy- 
roid secretion  (hyperthyroidism)  known  as  exophthalmic  goitre,  Graves's,  or  Base- 
dow's disease,  which  is  in  almost  all  cases  accompanied  by  enlargement  of  this 
gland,  with  other  symptoms,  among  the  more  prominent  of  which  are  increased 
rapidity  in  heart  action,  protrusion  of  the  e3'eballs,  muscular  tremor,  and  emacia- 
tion. According  to  Dr.  W.  G.  MacCallum  ^ :  "  The  most  characteristic  change  is 
enlargement  of  the  thyroid,  though  as  a  rule  not  to  great  size,  in  some  cases  not 
larger  than  the  normal,  in  a  very  few  actually  decreased  in  size.  Usually  the 
gland  tissue  is  harder  and  more  resistant  than  normal.  The  surface  of  the  organ 
is  somewhat  nodular  and  rough,  there  being  observed  fine  strands  of  fibrous  tissue 
traversing  the  glandular  substance,  separating  it  into  nodules.  In  these  nodules 
the  alveoli  are  smaller  than  normal,  and  are  no  longer  lined  with  low  cubical 
epithelium  and  filled  with  colloid  material."     This  careful  investigator  concludes: 

"  On  the  whole,  therefore,  the  only  lesions  in  this  disease  which  are  palpable 
and  constant  are  those  of  the  thyroid  and  of  the  lymphoid  apparatus  and  thymus. 
All  of  the  others  are  so  indefinite  and  so  often  completely  missed  that  it  is  dif- 
ficult to  convince  oneself  that  they  play  a  primary  role  in  the  disease. 

"  From  what  has  been  said  it  is  seen  that  with  the  appearance  of  definite  symp- 
toms of  exophthalmic  goitre  there  is'  always  the  same  change  in  the  thyroid.  In 
very  mild  and  indefinite  cases  it  may  be  possible  to  find  only  the  beginning  of  this 
change  in  some  part  of  the  walls  of  some  of  the  alveoli.  In  more  severe  cases  in 
the  early  stages  the  change  in  the  thyroid  may  be  in  foci  only,  while  the  rest 
remains  normal,  but  in  the  more  advanced  cases  the  typical  change  with  prolifera- 
tion of  the  epithelium  and  folding  of  the  walls  of  the  alveoli  is  invariably  found." 

Diagnosis. — The  diagnosis  depends  chiefly  upon  the  enlargement  and  visible 
pulsation  of  the  goitre. 

The  p)ulse-rate  is  rarely  below  ninety,  and  may  exceed  two  hundred  beats  to 
the  minute   (tachycardia). 

Exophthalmus  is  entirely  absent  in  about  one  third  of  the  cases,  and  often- 
times not  sufficiently  marked  to  attract  attention. 

The  character  of  the  tremor  is  rapid  and  vibratory,  noticeably  differing  from 
the  slow  tremor  of  paralysis  agitans.  Disturbances  of  digestion  are  the  rule  with 
marked  emaciation,  despite  liberal  feeding.  Perspiration,  often  profuse,  is  a  com- 
mon symptom  of  hyperthyreosis.  Barker,  in  the  "  American  Medical  Association 
Symposium,"  says :  "  An  important  part  of  the  physician's  function  lies  in  the  diag- 
nosis of  the  indications  and  contra-indications  for  surgical  interference.  Though 
nearly  all  patients  improve  on  rest  and  a  diet  which  does  not  stimulate  the  thy- 
roid (milk),  sodium  phosphate,  and  fortnightly  X-ray  exposures,  and  although 
occasionally  a  patient  will  get  well,  the  majority  go  backward  again  as  soon  as  treat- 
ment is  discontinued.  In  the  very  early  cases  surgery  is  capable  of  curing  nearly 
one  hundred  per  cent.  Even  in  the  outspoken  eases,  seventy-five  per  cent  can 
be  cured  by  operations  judiciously  planned  and  skillfully  performed,  and  the  mor- 
'  "Journal  Amer.  Med.  Association,"  June,  1907. 


THE   NECK 


337 


talitj',  now  about  five  per  cent,  can  be  further  reduced.  In  general,  medicine  up 
to  this  time  has  been  utterlj^  unable  to  obtain  results  comparable  with  these." 

Thyroidectomy. — The  lowering  of  blood-pressure  in  the  neck  is  essential.  The 
jDatient  should  be  strapped  to  the  table,  which  is  well  elevated  at  the  head,  or 
Dawbarn's  sequestration  method  should  be  practiced.  In  removing  a  solid  (fibrous) 
goitre,  it  is  advisable  to  confine  the  operation  to  a  single  lobe  and  the  isthmus, 
the  removal  of  which  usually  relieves  pressure  and  seemingly  retards  or  arrests  the 
hypertrophy'  of  the  remaining  lobe.  The  microscopical  examination  of  the  part 
removed  should  at  once  be  made  in  order  to  determine  the  necessity  of  a  complete 
extirpation,  which  should  be  done  at  once  if  cancer  or  sarcoma  is  discovered.  The 
same  conservative  method  should  be  applied  to  the  semisolid  form  of  goitre, 
removing  only  the  body  of  one  side  (not  the  isthmus  unless  seriously  involved), 
or,  if  possible,  after  opening  the  capsule,  enucleating  the  various  cysts  which  may 
he  most  superficial,  in  this  way  not  endangering  the  parathyroids  or  the  laryngeal 
nerves. 

In  cystic  goitre  a  cure  may  be  effected  by  drainage  without  resorting  to  the 
more  serious  operation  of  complete  extirpation.     These  drainage  operations  are 


^IG.  423. — Kocher's  collar  incision  dividing  the  skin  and  platysma  myoicles.  When  necessary  to 
divide  the  sterno-hyoid  and  sterno  thyroid  muscles  note  the  division  on  a  higher  plane  and  the 
sliort  cigarette  or  catgut  bundle-drain  at  the  interclavicular  notch.  (After  C.  H.  Mayo,  "Jour- 
nal of  the  American  Medical  Association,"  January  26,  1907.) 

■done  under  careful  antisepsis,  introducing  one  or  more  soft-rubber  tubes,  the 
number  dependent  upon  the  size  and  number  of  cysts  to  be  drained  (in  my  expe- 
rience never  more  than  two)  and  irrigating  daily  with  hot  salt  solution.  A  mild 
infection  occurred  in  several  of  the  author's  cases  toward  the  latter  part  of  the 
treatment,  but  produced  no  discomfort  or  septicaemia.  In  very  large  cysts  where, 
on   account   of   long-endured   pressure   with  cachexia,   the   patient's   resistance   is 


338 


THE   NECK 


low,  this  operation  is  preferable  to  extirpation,  which,  if  necessary,  can  be  done 
later  with  better  prospects  of  success.  For  complete  and  for  practically  all 
partial  extirpations  the  transverse  or  "  collar "  incision  of  Kocher  is  advised. 
This  incision  should  be  slightly  crescentic  in  shape,  as  it  crosses  the  neck 
over  the  middle  of  the  thyroid  body,  having  a  downward  curve  about  parallel 
with  the  crease  below  the  chin  (Fig.  423).  When  the  dissection  is  to  be  uni- 
lateral, it  need  only  extend  as  far  beyond  the  median  line  as  is  necessary  to  give 
ample  room,  which  is  essential  to  satisfactory  work  upon  this  vascular  organ. 
The  platysma  myoides  should  be  incised  with  and  included  in  the  skin  flaps  re- 
flected up  and  do"mi  as  far  as  may  be  required.  It  is  best  not  to  divide  the  hyoid 
muscles  which  cross  the  operative  field  when  the  organ  can  be  properly  exposed 
by  retraction,  but  in  cases  of  great  enlargement  they  should  be  divided  an  inch 
or  more  higher  than  the  incision  through  the  skin.  When  the  gland  is  exposed 
the  capsule  should  be  carefully  differentiated  from  the  overlying  layers  of  fascia 
and  opened  on  its  lateral  aspect  (Fig.  424).  If  the  disease  is  not  malignant  it  may 
easily  be  stripped  from  the  body,  either  with  the  curved  blunt  scissors  or  wiped  off 
with  a  gauze  swab.    All  blood  vessels  encountered  should  be  clamped  at  two  points 


Fig.  424. — The  capsule  opened  on  its  lateral  aspect,  exposing  the  thyroid  body  and  the  superior 
thyroid  artery.  (After  C.  H.  Mayo,  "Journal  of  the  American  Medical  Association,"  January  26, 
1907.) 


with  forceps,  divided,  and  tied  as  the  operation  proceeds.  On  account  of  the 
structures  to  be  avoided  it  is  advisable  to  apply  all  forceps  parallel  with  the  axis 
of  the  trachea.  By  working  well  in  behind  the  lobe  to  be  removed  and  lifting  it 
toward  the  middle  line,  the  thyroid  vessels  as  they  break  up  to  be  distributed  to  the 
gland  above  and  below  can  be  seen,  and  closely  associated  with  these,  usually  behind 
the  capsule,  are  the  parathyroids.    Moreover,  by  hugging  the  capsule  closely  in  the 


THE  NECK 


339 


lower  quadrant  (Fig.  425)  the  recurrent  laryngeal  nerve  need  not  be  seen.  In 
order  to  prevent  post-operative  oozing  a  catgut  ligature  should  be  tied  around 
the  isthmus  before  separating  it  from  the  extirpated  lobe.  In  closing  the  wound 
the  muscles  should  be  carefullj^  reunited  with  ten-day  catgut,  and  a  drainage  pimc- 
ture  made  in  the  middle  line  at  the  lowest  portion  of  the  cup-shaped  cavit}'  formed 


Fig.  425. — The  th-vToid  Kfted  and  reflected  toward  the  median  hne  in  order  to  lessen  hsemorrhage. 
Note  the  posterior  laver  of  the  capsule  undisturbed,  thus  minimizing  the  danger  of  injurj'  to 
the  parathvroids  and  "the  recurrent  larj'ngeal  nerve.  (After  C.  H.  Mayo,  "  Surgery,  Gynecology, 
and  Obstetrics,"  July,  1907.) 


by  turning  down  the  inferior  ilap  (Fig.  423).  A  ten-day  catgut  bundle  drain 
should  be  employed. 

In  fibrous,  and  in  those  forms  of  semisolid  goitre,  where  the  enlargement 
seems  chiefly  upon  one  side  and  involves  a  very  considerable  portion  of  the  gland, 
the  operation  just  described  should  be  performed,  but  so  important  is  the  function 
of  the  thyroid  body  that  when  the  cysts  are  few  in  number,  and  form  only  a 
small  portion  of  the  tumor  and  are  accessible,  it  is  advisable  to  attempt  the  sepa- 
rate removal  of  these  cysts  in  order  to  leave  as  much  of  the  functionating  organ  as 
possible.  This  may  at  times  be  accomplished  with  insignificant  bleeding  which 
can  be  controlled  by  the  use  of  adrenalin  solution,  and  by  the  method  of  suture 
with  catgut,  as  shown  in  Fig.  426. 

In  cystic  goitre,  where  there  is  one  large,  or  perhaps  two  or  three  smaller 
separate  cavities  filled  with  the  coffee-colored  material  common  to  this  form  of 
thyroid  tumor,  extirpation  should  not  be  attempted  imtil  a  careful  and  thorough 
effort  has  been  made  to  obliterate  the  cysts  by  drainage.  In  six  cases  the  author 
has  followed  this  method  without  an  accident  and  with  a  satisfactory  result  in 
each  instance.  The  rubber-tube  drainage  was  made  from  the  lowest  point,  as 
determined  by  careful  aspiration.  Irrigations  with  hot  salt  solution  should  be 
used  once  or  twice  every  dav. 


340 


THE   NECK 


On  aecouBt  of  the  low  resistance  of  individuals  affected  with  Basedow's  or 
Graves'  disease,  even  greater  precautions  in  treatment  are  essential  than  for  other 
lesions  of  the  thyroid.  In  view  of  the  results  reported  by  Drs.  Eogers  and  Beebe,^ 
from  the  use  of  a  specific  serum,  this  agent  in  conjunction  with  a  careful  dietetic 
and  rest  treatment,  should  be  thoroughly  tried  before  resorting  to  a  surgical 
operation. 

In  no  department  of  surgery  has  more  gratif3dng  progress  been  made  than 
in  the  operative  treatment  of  lesions  of  the  thyroid.  Within  the  last  half  cen- 
tury it  was  considered  a  procedure  so  formidable  as  to  be  practically  forljidden 
until  the  courage  and  skill  of  Green  of  Maine  forced  its  recognition.  To-day 
two  surgeons  of  Switzerland,  Kocher,  father  and  son,  have  performed  several 
thousand  thyroidectomies  with  a  deatliTrate  in  all  cases  not  exceeding  three  per 
cent. 

Even  in  exophthalmos,  where  the  cachexia  is  well  marked  and  the  resistance 
is  low,  by  thorough  preparation  and  the  exercise  of  proper  care  a  successful  issue 


Fig.  426 — Aluscle  suture  and  interlocking  suture  of  cut  gland  with  ten-day  cliromic-ised  catgut. 
(C.  H    Mayo,  from  "Journal  of  Surgery,  Gynecology,  and  Obstetrics,"  July,  1907.) 


is  the  rule.  Avoiding  when  possible  even  the  small  risk  of  shock  from  ether  or 
chloroform  narcosis,  using  cocaine  infiltration  and  morphia  instead,  and  in  ex- 
treme cases  resting  content  to  cut  off  the  circulation  of  a  single  thyroid  artery, 
are  among  the  conservative  measures  which  are  advised.  Symptoms  of  diminished 
thyroid  toxasmia  will  follow  this  lessening  of  the  blood  supply,  and  with  the  pa- 

'  J.  A.  Booth,  "Med.  Record,"  June  15,  1907,  p.  980;   "Transactions  of  the  American  Medi- 
cal Association,"  1907. 


THE   NECK 


341 


tient's  improved  condition  the  operation  can  be  carried  on  in  various  sittings 
to  a  complete  and  safe  removal  of  the  organ.  The  vast  majority  of  cases  of 
exophthalmus  taken  early  will  not  reqviire  this  extreme  precaution,  but  the  neces- 
sity of  great  care  cannot  be  too  strongly  expressed. 

In  all  operations  where  the  substance  of  the  diseased  thyroid  is  exposed,  fre- 
quently repeated   irrigation  with  hot  salt  solution   should  be  made   in   order   to 


Fig.  426o.— Greatest 


[jusure  of  thyruid  witli  liigli  muscle  section.      (C.  H.  Mayo,  fr 
Surgtery,  Gynecology,  and  Obstetrics,"  July,  1907.) 


prevent  the  possible  absorption  of  an  excess  of  thyroid  secretion  which  may  come 
in  contact  with  the  wound  as  the  result  of  traumatism. 

In  the  after-treatment,  when  all  parts  of  the  gland  have  been  removed,  the 
administration  of  thyroid  extract  is  considered  necessary  in  postponing  the  con- 
dition of  myxoedema  which  results  in  many  of  these  cases. 

Hydatid  cysts  are  occasionally  met  with  in  the  thyroid.  The  diagnosis  will 
be  determined  by  aspiration,  and  they  should  be  treated  by  incision  and  drainage. 


The  Lakynx  .^nd  Teachea 

The  operations  upon  these  organs  in  the  neck  are  subhyoid  pharyngotomy,  thy- 
rotomy,  laryngotomy,  laryngo-tracheotomy,  tracheotomy,  and  exsection  of  the  larynx 
or  laryngectomy. 

In  the  removal  of  large  tumors  situated  in  the  laryngo-pharynx,  subhyoid 
pharyngotomy,  as  advised  by  Dr.  Walter  F.  Chappell,^  may  be  performed.  A 
transverse  incision  is  made  and  the  thyro-hyoid  membrane  opened,  permitting  the 
operator  to  pull  the  epiglottis  forward".  The  tumor  may  now  be  removed,  either 
by  transfixing  or  tying  the  pedicle  with  strong  ten-day  chromieized  catgut.  If 
small  and  non-vascular,  the  electro-thermal  cautery  may  be  substituted  for  the 
ligature. 

1  "Med.  Record,"  July  13,  1907. 


342 


THE  NECK 


As  a  precautionary  measure,  tracheotomy  may  be  performed,  and  if  this  is  not 
deemed  necessary,  every  preparation  should  be  made  for  its  immediate  performance. 
In  closino-  the  wound,  the  thyro-hyoid  membrane,  the  various  muscular  layers,  and 
the  skin  should  be  closed  by  separate  rows  of  sutures. 

Thyrotomy  is  indicated  in  the  removal  of  neoplasms  or  foreign  bodies  from  the 
larynx,  which  cannot  be  reached  through  the  mouth  by  the  aid  of  the  laryngoscope 
and  forceps  or  snare.  The  patient  should  be  placed  upon  the  table,  with  the  head 
well  depressed.  Make  a  perpendicular  incision  from  near  the  center  of  the  hyoid 
bone,  in  the  median  line  of  the  pomum  Adami,  as  far  down  as  the  cricoid  cartilage. 
The 'bleeding  is  thoroughly  arrested,  and  the  two  wings  of  the  thyroid  cartilage 
divided  exactly  in  the  angle  of  union.  This  shordd  be  done  with  great  care,  in 
order  to  avoid"  wounding  the  vocal  bands,  which  are  attached  on  either  side  of  the 
median  line,  in  front.  If  at  this  stage  of  the  operation  a  tenaculum  is  inserted,  on 
either  side,  the  alae  may  be  drawn  apart,  freely  exposing  the  interior  of  the  larynx. 
In  closing  the  wound  the  cartilages  are  not  included  in  the  sutures,  it  being  suffi- 
cient to  bring  the  edges  of  the  skin  together. 

In  laryngotomy  the  opening  is  made  through  the  crico-thyroid  membrane.  It 
is  indicated  in  oedema  of  the  glottis,  obstruction  of  the  larynx  by  new  growths, 
foreign  bodies,  and  exceptionally  in  rapid  inflammatory  swelling  of  the  tonsils  or 
pharj^nx,  with  occlusion  of  the  larj'nx. 

When  the  emergency  demands  it,  rapid  laryngotomy  may  be  performed  as  fol- 
lows :  Make  a  single  incision  from  the  notch  in  the  upper  margin  of  the  thyroid 
cartilage,  in  the  median  line,  to  the  lower  edge  of  the  cricoid  ring,  then  turn  the 
knife  edge  upward  and  thrust  the  point  through  the  crico-thyroid  membrane.  A 
hook  should  now  be  quickly  inserted  on  either  side,  and  the  edges  of  the  wound 
separated.  Traction  not  only  opens  the  wound  in  the  membrane  to  admit  the  air 
more  freely,  but  it  also  arrests  the  bleeding.  When  tenacula  cannot  be  had,  a  fair 
substitute  may  be  extemporized  from  wire,  or  the  ordinary  metal  hairpin.  The 
opening  in  the  membrane  maj'  be  enlarged  by  a  trans- 
verse incision  when  necessary. 

When  expedition  is  not  urgent,  the  bleeding  from 
the  woimd  in  the  integument  should  be  arrested  be- 
fore the  opening  into  the  larjmx  is  made. 

If  it  is  necessary  to  keep  the  wound  open,  a  silver 
trachea  canula  (Fig.  427)  should  be  inserted.  This 
instrument  is  secured  by  a  tape  tied  around  the  neck. 
When  it  becomes  obstructed,  the  inner  canula  should 

be  withdrawn,  cleansed,  and  reinserted,  and,  if  neces- 

FiG.  427.-Double  trachea  tube,      sary,  the  larger  tube  remaining  in  the  larynx  should 

silver,  plain.  be  brushed  out  with  a  small  brush  or  mop.     When 

this  instrument  is  worn  it  should  be  carefully  watched, 

as  long  as  any  danger  of  its  becoming  obstructed  exists.    It  may  be  worn  indefinitely 

in  cases  of  permanent  laryngeal  stenosis. 

Laryngotomy  without  a  Tube. — When  a  canula  is  not  at  hand,  a  needle,  armed 
with  fine,  strong  silk,  should  be  passed,  on  either  side,  through  the  integument  and 
cricoid  membrane,  brought  out  through  the  opening  in  the  larynx,  and  the  suture 
tied.  It  is  best  to  employ  two  sutures  in  each  side  of  the  wound.  These  may 
be  tied  behind  the  neck,  or  attached  to  bits  of  adhesive  plaster  and  fastened 
to  the  integument,  so  as  to  keep  the  wound  open.  A  strip  of  plaster  should 
be  laid  on  each  side  of  the  wound,  to  prevent  the  thread  from  cutting  into  the 
integument. 

Laryngo-tracheotomy  (an  operation  rarely  performed)  consists  in  extending  the 
incision  of  laryngotomy  through  the  cricoid  cartilage,  and  the  upper  one  or  two 
rings  of  the  trachea. 

Tracheotomy  is  more  frequently  done  than  either  of  the  operations  just  given. 
The  trachea  may  be  opened  (1)  alDOve  the  isthmus  of  the  thyroid  body,  the  upper 
three  or  four  rings  being  divided;  (2)  the  isthmus  may  be  tied  with  a  double 
ligature,  divided,  and  the  trachea  opened  beneath  it;  (3)  the  opening  into  the  tube 
may  be  altogether  below  the  isthmus. 


THE   NECK  343 

It  will  rarely  he  found  necessary  to  divide  the  isthmus.  The  operation  above 
the  isthmus  is  simpler,  and  should  be  preferred  in  all  cases  wiiere  the  obstruction 
is  in  the  larynx.  For  the  removal  of  a  foreign  body  lodged  in  the  iDifurcation  of 
the  trachea,  or  in  either  bronchus,  the  lower  procedure  should  be  adopted.  This 
operation  should  also  be  preferred  in  diphtheritic  eroup  when  all  other  measures 
have  failed.  The  results  achieved  with  the  laryngeal  tube  of  Dr.  O'Dwyer,  of  iSTew 
York,  justifies  a  faithful  trial  with  this  instrument  before  resorting  to  the  formid- 
able operation  of  tracheotomy  in  diphtheritic  croup. ^ 

High  Operation. — Place  the  patient  on  the  back,  in  such  a  position  that  the 
head  falls  well  over  the  end  of  the  table.  If  an  antesthetic  is  not  given,  one  assist- 
ant should  hold  the  extremities  immovable,  while  a  second  steadies  the  head.  The 
operator  should  stand  to  the  patient's  right,  facing  the  light.  It  is  important  that 
the  head  be  held  so  that  the  nose  and  symphysis  menti  will  be  directly  in  line 
with  the  interclavicular  notch  and  umbilicus,  for  if  this  precaution  is  not  taken 
the  trachea  may  be  displaced,  an  accident  which  might  lead  to  great  annoyance, 
especially  in  children,  in  whom  this  tube  is  always  very  small.  The  incision  should 
be  exactly  in  the  median  line,  commencing  at  the  center  of  the  thyroid  cartilage 
and  extending  downward  one  inch  and  a  half,  or  more  if  necessary.  The  edges 
of  the  wound  should  be  separated  by  retractors,  and  the  incision  continued  do'mi 
to  the  tube.  All  bleeding  should  be  arrested  by  the  forceps  and  ligature  before  the 
trachea  is  opened,  for  fear  of  suffocation  from  the  entrance  of  blood. 

In  some  subjects  it  will  be  found  that  the  isthmus  of  the  thyroid  body  is  situated 
so  high  that  an  opening  sufficiently  long  cannot  be  made  without  displacing  it 
downward.  This  may  be  done  by  dividing  with  the  curved  scissors  the  muscular 
and  ligamentous  bands  which  are  attached  to  the  isthmus  below,  and  the  hyoid 
bone  and  thyroid  cartilage  above.  This  section  should  be  made  on  either  side  of 
the  incision,  opposite  the  first  ring  of  the  trachea.  After  all  bleeding  has  ceased, 
the  knife  should  be  carried  into  the  trachea  with  the  edge  directed  upward,  and 
the  two  or  three  upper  rings  divided. 

Low  Operation. — The  incision  throitgh  the  integument  extends  from  the  cricoid 
cartilage  to  the  level  of  the  interclavicular  notch.  Separate  the  sterno-hyoid 
muscles  in  the  median  line,  and  carry  the  dissection  carefully  down  to  the  trachea, 
avoiding  the  isthmus  of  the  thyroid  body  and  the  inferior  thyroid  vein,  a  branch 
of  which  is  in  front  of  this  tube.  The  anterior  jugular  vein  occasionally  is  in  the 
median  line.  Any  of  these  vessels  coming  within  the  line  of  incision  should  be 
secured  with  a  double  ligature  before  being  divided.  The  trachea  will  be  found 
deeply  situated,  and  should  be  incised  through  four  or  five  rings,  in  the  same 
manner  as  advised  in  the  preceding  operation.  If  a  trachea  tube  is  not  at  hand, 
the  operation  may  he  completed,  as  advised  in  larv-ngotomy,  without  a  tube. 

FoEEiGX  Bodies  in  the  Laetxs,  Teachea,  and  Beoxchi 

Foreign  bodies  in  the  respirator)'  tract  are,  in  almost  all  instances,  introduced 
by  way  of  the  larynx,  into  which  they  may  fall  by  gravity  or  be  drawn  in  by  the 
suction  force  of  the  inspiratory  efl:ort.  Occasionally  they  enter  directly  from  with- 
out, as  ia  stab  or  gunshot  wounds,  or  may  make  their  way  in  from  the  oesophagus 
by  perforation  or  from  the  rupture  of  an  aneurism  or  abscess.  Pieces  of  coin, 
buttons,  teeth,  seeds,  threads,  pins,  blow-gun  darts,  shot,  particles  of  food,  etc., 
are  among  the  most  frequent  substances  lodged  in  the  air  passages.  A  foreign 
body  may  lodge  just  behind  the  epiglottis,  across  the  rima  glottidis,  in  the  ventricle 
between  the  true  and  false  bands,  between  the  vocal  cords,  or.  passing  these,  it 
may  descend  into  the  trachea  or  bronchus.  If  it  l}e  a  solid  and  smooth  body, 
it  will  pass  into  the  bronchus  and  continue  to  descend  until  the  smaller  diameter 
of  the  tube  arrests  its  progress.  Any  suljstance  with  projecting,  sharp  edges,  or 
long  and  pointed,  as  a  pin  or  fish  bone,  may  become  lodged  across  the  windpipe 
at  any  point. 

The  symptoms  of  a  foreign  body  in  the  air  passages  are-  immediate  and  remote. 

1  See  Chapter  on  Diphtheria. 


344 


THE   NECK 


Strano-ulation,  cough,  and  cyanosis  immediately  after  the  escape  of  any  substance 
backward  from  the  mouth  or  nose,  or  matter  which  has  been  regurgitated  from  the 
stomach,  always  suggest  the  entrance  of  foreign  matter  into  the  larynx  or  trachea. 
In  some'  cases  death  ensues  almost  instantly  from  asphyxia.  In  others  the  symp- 
toms of  strangulation  last  for  a  few  moments  and  then  disappear,  leading  the 
patient  or  attendant  to  believe  that  the  foreign  body  has  been  coughed  out  or 
swallowed.  The  momentary  cyanosis  and  strangulation  are  caused  by  spasm  of  the- 
laryngeal  muscles,  induced  by  direct  irritation  from  the  foreign  body.  As  soon 
as  these  relax  a  forcible  inspiratory  effort  may  carry  the  substance  downward  to 
the  trachea  or  bronchus,  or  the  expiratory  cough  may  have  discharged  it  into  the 
mouth.  In  any  event,  the  symptoms  of  asphyxia  disappear  unless  ■  the  offending 
substance  is  so  large  that,  even  when  sucked  into  the  trachea,  it  completely  occludes 
this  tube.  The  remote  symptoms  of  foreign  bodies  in  the  air  passages  are  chiefly 
inflammatory.  Trachitis,  bronchitis,  pneumonia,  gangrene,  and  abscess  may  ensue. 
Abscess  and  gangrene  are  rare.  Bronchitis  is  inevitable,  and  localized  or  lobar 
pneumonia  is  not  infrequent. 

The  diagnosis  may  be  determined  by  the  X-ray  or  by  laryngoscopic  inspection, 
palpation  (either  direct  or  intermediate),  and  by  auscultation,  together  with  a 
due  regard  for  the  sensations  experienced  by  the  patient.  Direct  palpation  is  only 
possible  when  the  substance  is  lodged  in  the  larynx,  since  the  tip  of  the  finger 
cannot  be  carried  beyond  this  point. 

Auscultation  is  of  great  aid  to  diagnosis,  especially  when  the  body  has  passed 
deep  into  the  respiratory  tract.  Diminution  or  absence  of  the  normal  vesicular 
murmur  over  one  entire  lung  indicates  the  partial  or  complete  occlusion  of  one 
primary  bronchus  by  the  foreign  body.  If  this  interference  is  limited  to  only  a 
portion  of  the  lung,  the  indication  is  that  the  body  has  passed  into  one  of  the 
subdivisions  of  the  bronchus. 

The  compensatory  increase  of  the  normal  vesicular  respiration  in  the  opposite 
lung  will  be  proportioned  to  the  interference  with  the  function  of  the  affected  side. 
When  a  narrow  body  becomes  lodged  in  the  trachea  or  bronchus,  its  presence  is 
indicated  by  a  sibilant  or  hissing  sound,  heard  with  greatest  intensity  over  the 
point  of  lodgment,  and  carried  upward  and  downward  with  the  expiratory  or 
ins23iratory  movement. 

The  presence  of  pain  persisting  in  a  given  locality  points  to  the  seat  of  lodg- 
ment of  the  foreign  substance.  Persistent  spasm  of  the  larynx  until  tolerance  is 
acquired  suggests  lodgment  in  the  ventricle  of  this  organ. 

Treatment. — The  immediate  indication  is  the  prevention  of  fatal  asphyxia,  and 
this  may'require  rapid  laryngotomy  or  tracheotomy,  and,  in  exceptional  instances, 
the  resuscitation  of  the  patient  by  the  method  of  Sylvester.  As  soon  as  this  danger 
is  obviated,  the  removal  of  the  foreign  body  may  be  undertaken.  It  is  well  to 
remember  that  symptoms  of  asphyxia  may  be  produced  from  the  presence  of  viscid 
mucus  adhering  to  the  rima  glottidis,  causing  obstruction  and  spasm. 

AVhen  fatal  asphyxia  is  not  threatened,  no  immediate  operation  is  indicated. 
The  patient  should  be  turned  head  downward  and  violently  shaken,  and  .at  the 
same  time  made  to  cough  or  sneeze.  If  the  substance  is  smooth  or  heavy,  it  may 
be  dislodged  and  expelled  in  this  manner. 

If  this  procedure  is  unsuccessful,  the  question  of  operation  should  be  considered. 
If  the  body  can  be  located  in  the  larynx,  it  can  readily  be  removed  by  the  opera- 
tion of  thyrotomy  if  the  patient  is  a  child,  or  by  laryngotomy  and  the  introduction 
of  the  little  finger  into  the  organ  through  the  wound  in  the  adult,  pushing  the 
offending  substance  upward  into  the  pharynx.  Either  of  these  procedures  is  prac- 
tically free  from  danger.  When  the  foreign  body  has  passed  into  the  trachea  or 
bronchi,  the  necessity  for  operation  will  depend  upon  its  size,  shape,  and  location. 
If  it  is  small,  and  produces  no  marked  disturbance  of  respiration,  and  is  deeply 
lodged,  no  effort  should  be  made  to  remove  it,  for  the  following  reasons :  When 
small  it  is  not  apt  to  inflict  serious  damage;  tracheotomy  and  the  introduction  of 
instruments  into  the  respiratory  tract  are  not  without  risk;  lastly,  the  uncertainty 
of  finding  or  dislodging  a  small  body  should  be  taken  into  consideration. 

When,  however,  the  character  of  the  foreign  body  is  such  that  its  presence  is 


THE   NECK  345 

a  source  of  great  danger  to  the  patient,  and  it  cannot  be  removed  without  opera- 
tion, surgical  interference  is  demanded.  The  position  for  tlie  patient  is  the  same 
as  for  traelieotomy,  and  this  operation  sliould  be  done  as  low  down  as  possible. 
When  the  trachea  is  opened,  the  little  finger  should  be  carried  downward  to  the 
bifurcation  in  the  hope  of  locating  the  body,  and,  if  discovered,  it  should  be  grasped 
with  a  pair  of  forceps  and  removed.  If  it  is  not  encountered  below,  the  upper 
portion  of  the  tube  should  be  examined  in  the  same  way.  If  it  cannot  be  reached 
by  the  finger,  the  angular  alligator  forceps  (Fig.  428)  should  be  carried  into  the 
bronchial  tubes,  carefully  regarding  any  arrest  in  the  jjrogress  of  the  instrument. 


Fig.  428. — Forceps  for  removing  foreign  bodies 
from  the  trachea  and  bronchi. 

A  solid  or  large  body  may  be  felt  and  seized  without  great  difficulty.  A  small, 
light  substance  may  be  touched  without  any  sense  of  resistance  to  the  hand  of  the 
operator.  If  it  cannot  be  recognized,  the  point  of  the  instrument  should  be  car- 
ried into  the  bronchus  in  which  the  body  is  located,  the  jaws  separated,  and,  while 
open,  carried  about  half  an  inch  farther  in,  and  then  closed  and  withdrawn  in  order 
to  see  if  the  object  has  been  grasped.  This  manoeiivre  is  repeated  several  times 
until  the  whole  length  of  the  bronchus  has  been  searched.  If  the  foreign  body 
is  not  found,  it  will  be  judicious  to  search  in  the  opposite  bronchus,  for  it  is 
possible  for  it  to  have  been  dislodged  in  the  course  of  the  exploration,  and  carried 
by  the  respiratory  effort  into  the  trachea  and  down  into  the  other  tube.  If  proper 
forceps  cannot  be  obtained,  a  loop  of  silver  wire  may  be  used. 

The  exploration  of  the  trachea  should  be  done  with  great  care  not  to  inflict 
unnecessary  violence  upon  the  mucous  membrane. 

If  the  body  is  removed,  the  wound  may  be  left  to  heal  by  granulation,  simply 
closing  it  with  adhesive  strips,  or,  if  the  patient  has  borne  the  anassthetic  well,  it 
will  be  better  to  stitch  the  trachea  with  catgut,  and  the  edges  of  the  wound  sepa- 
rately with  the  same  substance.  If  the  object  is  not  found,  the  tracheal  wound 
should  be  kept  open  by  inserting  a  large  trachea  tube,  or  by  sewing  the  tracheal 
rings  to  the  edges  of  the  divided  integument  and  keeping  the  wound  open  by  tying 
the  strings  behind  the  neck. 

When  a  foreign  body  is  lodged  deep  in  the  lung  and  is  producing  dangerous 
inflammation  of  this  organ,  or  the  pleura,  and  is  so  situated  that  it  can  be  reached 
by  resection  of  one  or  more  ribs,  surgical  interference  may  be  entertained. 

Laryngectomy,  or  exsection  of  the  larynx,  although  a  formidable  operation,  is, 
\mder  certain  conditions,  justifiable.    It  may  be  partial  or  complete. 

The  conditions  which  justify  this  procedure  are  the  invasion  of  this  organ  by 
malignant  neoplasm,  and,  in  rare  instances,  destructive  chondritis,  with  infiltration 
and  threatened  occlusion  of  the  respiratory  tract.  If,  after  a  careful  study  of  the 
case,  the  surgeon  is  convinced  that  there  is  a  fair  probability  of  relief  from  pain 
and  prolongation  of  life  by  the  removal  of  the  diseased  structures,  greater  than  he 
would  be  likely  to  obtain  by  tlie  palliative  operation  of  tracheotomy,  he  is  justified 
in  advising  the  operation.  When  the  tissues  about  the  larynx  are  widely  infiltrated 
with  the  malignant  neoplasm,  the  operation  is  not  justifiable. 

Complete  laryngectomy  is  performed  as  follows:  Under  chloroform  narcosis  an 
incision  is  made  from  above  the  hyoid  bone  in  the  median  line  over  the  pomum 
Adami  and  downward  in  the  direction  of  the  middle  line  of  the  manubrium.  A 
transverse  incision  crosses  this  at  the  level  of  the  coracoid  cartilage,  taking  care 
not  to  wound  the  great  vessels  and  important  structures  lying  on  the  side  of  the 
neck.  A  careful  dissection  is  made  and  all  haemorrhage  controlled  as  the  operation 
proceeds.  The  wound  should  be  perfectly  dry  when  the  division  of  the  trachea 
is  effected.     After  this  is  exposed  and  dissected  free  from  the  a?sophagus  by  the 


346  THE   NECK 

finger,  a  probe-pointed,  curved  bistoury  should  be  carefully  inserted  between  the 
oesophagus  and  the  trachea  at  the  point  at  which  the  windpipe  is  to  be  divided, 
and  when  everything  is  ready,  a  quick  division  of  the  trachea  is  made  and  the 
dissection  completed  from  beloiv  upward.  In  this  way  no  bleeding  can  escape 
into  the  respiratory  tract.  By  placing  the  patient  with  the  head  considerably  lower 
than  the  feet,  I  have  done  this  operation  without  the  use  of  the  Trendelenburg  or 
any  similar  tube.  In  fact,  this  complicated  apparatus  is  a  hindrance  rather  than 
an  aid  to  rapidity  in  this  ptrocedure.  It  is  usually  necessary  to  treat  these  wounds 
by  the  open  method,  closing  only  the  angles  of  the  incisions.  Great  after-care  is 
essential  in  preventing  the  descent  of  saliva  or  ingested  liquids  into  the  trachea. 
When  the  operation  does  not  of  necessity  demand  the  removal  of  a  portion  of  the 
anterior  wall  of  the  cesophagus  or  that  portion  of  the  pharynx  immediately  below 
the  tongue,  and  this  is  opened  into  the  upper  portion  of  the  operative  field,  this 
part  of  the  wound  should  be  closed  at  once  so  that  the  patient  may  be  able  to 
swallow  without  the  use  of  the  stomach  tube.  The  tube  should  be  held  in  reserve 
in  all  cases  for  the  purpose  of  feeding.  It  is  always  advisable  to  sew  the  integu- 
ment either  to  the  edges  of  the  tracheal  wound  or  to  leave  this  projecting  from  the 
partially  closed  wound  to  prevent  septic  infiltration  as  well  as  to  obviate  the  danger 
of  emjihysema. 

Partial  laryngectomy  is  pierformed  in  the  same  general  way  as  the  complete 
operation.  The  value  of  morphine  as  au  adjuvant  in  securing  profound  narcosis 
with  the  minimum  of  chloroform  or  ether  cannot  be  overestimated,  especially  in 
connection  with  this  particular  operation.  If  to  this  be  added  the  tactful  and' 
judicious  employment  of  sequestration  and  cocaine,  there  will  be  very  little  need 
of  either  of  the  general  anaesthetics. 

Neoplasms  of  the  Larynx  and  Tracliea. — Almost  every  form  of  new  growth  has 
been  removed  from  the  larynx.  iSTo  portion  of  the  organ  is  exempt.  The  symp- 
toms are  referable  to  the  location  of  the  neoplasm  and  to  its  size,  and  in  a  certain 
sense  to  its  shajDC.  Those  situated  upon  the  vocal  bands  are  first  noticed,  on  account 
of  interference  with  the  voice.  .  A  neoplasm  may  develop  in  the  ventricle,  and  not 
be  noticed  until  it  encroaches  upon  the  cords.  Dyspnoea  occurs  earlier,  when  the 
tumor  is  situated  upon  the  rima  glottidis. 

Cough  is  not  a  prominent  symptom,  for  the  reason  that  the  slow  and  progressive 
development  of  the  neoplasm  gradually  accustoms  the  larynx  to  its  presence.  Spas- 
modic cough  does,  however,  occur  in  pedunculated  growths,  which  are  moved  to  and 
fro  as  the  air  riTshes  in  and  out  of  the  larynx. 

The  diagnosis  may  be  made  from  the  symptoms  detailed,  but  chiefly  by  palpa- 
tion and  the  laryngoscope.  The  location  is  simple,  but  the  differentiation  as  to  the 
character  of  the  growth  is  at  times  difficult.  Papillomata  are  most  frequently  met 
with,  and  pafiilloma  in  the  larynx  possesses  the  same  general  properties  observed 
in  these  growths  in  more  exposed  quarters.  They  are  most  commonly  found  upon 
the  vocal  bands.  The  tumor  may  appear  in  the  mirror  as  a  single  wartlike  fungus, 
or  pinkish-gray  tuft  upon  the  cords  or  laryngeal  wall,  or  there  may  be  several  which 
fill  a  great  part  of  the  opening.  The  filiroid  laryngeal  polypi  (fibromata)  are 
chiefly  pyriform,  pedunculated,  and  smooth,  in  location  and  color  resembling  the 
papillomata. 

Enchondromata  of  the  larynx,  less  frequently  observed  than  the  two  preceding 
neoplasms,  are  developed  from  the  cartilage  proper  of  the  larynx.  They  are  usually 
seen  in  the  vicinity  of  the  crico-arytenoid  articulation.  Cystic  tumors  are  rare. 
Occlusion  of  the  duct  of  the  sacculus  laryngis  will  lead  to  the  appearance  of  a 
tumor  in  the  ventricle,  between  the  true  and  false  bands.  Other  cysts  may  result 
from  simple  follicular  occlusion.  Telangiectasis,  or  angeioma,  is  a  still  rarer  form 
of  laryngeal  tumor.  Carcinoma  (epithelioma)  is,  unfortunately,  not  a  rare  disease 
of  this  organ.  Sarcoma  is  very  rarely  met  with.  Epithelioma  of  the  larynx,  in 
common  with  all  malignant  (as  well  as  benign)  neoplasms,  occurs  chiefly  at  the 
irpper  portions  of  the  organ. 

The  treatment  of  all  forms  of  benign  tumors  of  the  larynx  is  their  removal 
with  the  knife,  scissors,  the  snare,  or  caustics.  Eemoval  of  malignant  growths, 
to  an  extent  sufficient  to  prevent  recurrence,  without  a  total  or  partial  laryngec- 


THE   NECK  347 

tomy,  is  rarely  possible.  Benign  growths,  especially  tlie  smaller  new  formations, 
may  be  removed  best  by  chromic-acid  crystals  directly  applied  at  frequent  sittings. 
A  small  pellet  of  cotton  is  attached  to  the  end  of  the  applicator,  and  a  particle 
of  chromic  acid,  of  convenient  size,  is  picked  up  on  this  and  carried  do^m  to  the 
tumor.  The  crystals  adhere  to  the  ILat  until  they  come  in  contact  with  a  moist 
surface.  In  carrying  the  instrument  through  the  mouth,  care  must  be  taken  to 
avoid  touching  the  mucous  surfaces.  Epithelioma  in  its  early  development  may 
be  successfully  destroyed  bj'  this  escharotic.  The  operator  shoiild  take  advantage 
of  the  anesthetic  jjroperties  of  cocaine  to  render  the  pharynx  and  larjTix  tolerant 
of  manipulation.  Xitrate  of  silver  maj-  also  be  used,  but  is  inferior  to  chromic 
acid. 

Avulsion,  or  tearing  away  the  neoplasm,  is  a  useful  and  frequentlj'  employed 
method.  For  this  purpose  various  forms  of  forceps  have  been  used.  Peduncu- 
lated tumors  may  be  snared  and  cut  away  with  the  wire  loop  of  Jarvis.  Fibro- 
mata often  adhere  so  tenaciously  that  they  cannot  be  torn  away  without  damage 
to  the  larynx.  Care  should  be  taken  to  regulate  the  force  so  that  injury  to  the 
vocal  bands  or  the  smaller  cartilages  may  be  avoided. 

The  operations  of  thi/rotomy  and  subhyoid  phar3rngotomj' — ^lieretofore  described 
— gives  the  best  command  of  the  cavity  of  this  organ,  and  allow  the  more  thorough 
and  safe  removal  of  the  neoplasm. 

Neoplasins  similar  in  character  to  those  found  in  the  larynx  may  occur  in 
the  trachea  and  bronchi.  The  location  of  the  new  growth  may  be  determined  from 
the  physical  signs. 

The  treatment  is  strictly  surgical,  and  involves  phj'sical  exploration  of  the 
respirator)'  tract,  with  avulsion  or  excision  of  the  growth,  or  the  introduction  of 
the  trachea  tube  to  prevent  asphyxia. 

Phaeyxx  axd  CEsophagus 

Pliarynx. — ISTeoplasm  of  the  walls  of  this  cavity  are  comparatively  rare.  They 
occur  usuallj'  in  the  vault,  and  are  attached  to  the  mucous  membrane,  or  peri- 
osteum, beneath  the  basUar  process.  The  treatment  consists  in  removal  by  the 
forceps,  the  snare,  or  galvano-cautery,  or,  if  the  tumor  is  of  considerable  size,  by 
the  knife.  In  some  instances  deligation  of  both  external  carotid  arteries  is  ad- 
visable, or  Dawbarn's  more  radical  procedure  of  excision  of  these  arteries  ^rith  all 
their  upper  branches  and  anastomoses. 

Foreign  bodies  are  not  infrequently  lodged  in  this  organ.  They  may  be  dis- 
covered by  inspection  with  the  pharragoscope,  or  felt  wdth  the  index-finger. 

The  ireatment  is  removal  by  the  aid  of  the  mirror  and  curved  forceps. 


•    OESOPHAGUS 

Bupture  of  the  oesophagus,  though  several  instances  are  recorded,  is  exceed- 
ingly rare.  The  accident  occurs  in  forced  efforts  at  deglutition  after  overdisten- 
tion  of  the  stomach.  The  symptoms  are  intense  pain  in  the  region  of  the  rup- 
ture— which  is  usually  in  the  long  axis  of  the  tube  and  near  the  diaphragm — 
followed  by  rapid  and-  fatal  collapse.  Vomiting  does  not  occur,  although  the 
contents  of  the  stomach  may  be  emptied,  in  part,  into  the  mediastinum. 

Foreign  Bodies. — The  lodgment  of  bodies  in  the  oesophagus,  resulting  in  par- 
tial or  complete  occlusion,  is  of  frequent  occurrence.  The  symptoms  depend  in 
great  part  upon  the  character  of  the  foreign  substance.  A  sharp  and  narrow 
body — as  a  bone,  pin,  needle,  or  splinter  of  wood^-will  produce  pain  at  the  seat 
of  lodgment,  but  will  allow  the  passage  of  liquid  and  semisolid  ingesta.  Soft, 
compressible  particles  of  large  size  maj'  completely  occlude  the  tube,  and  cause 
pressure  upon  the  trachea  sufficient  to  induce  marked  asphyxia.  The  diagnosis 
must,  in  part,  be  based  upon  these  symptoms  and  the  history  of  the  accident. 
Pressure  over  the  seat  of  lodgment  of  a  sharp  substance  will  exaggerate  the  sense 
of  pain,  while  the  inability  to  swallow  liquids  will  indicate  the  complete  occlusion 


348 


THE   NECK 


of  the  tube.     The  introdnction  of  the  elastic  oesophageal  sound   (Fig.  429)   will 
demonstrate  the  presence  of  any  occluding  body. 

In  order  to  introduce  this  instrument,  lubricate  it  with  the  white  of  an  egg, 
or  glycerin,  and  cause  the  patient  to  throw  the  head  back  so  as  to  bring  the  axis- 
of  the  mouth  and  pharynx  in  line  with  that  of  the  oesophagus.     Insert  the  bougie 


Fig.  429. — CEsophageal  sound  and  bulbs. 

SO  that  the  point  will  glide  over  the  root  of  the  tongue  and  strike  the  posterior 
wall  of  the  pharynx  behind  the  larynx.  The  tongue  should  not  be  drawn  out 
of  the  mouth.  Spasm  of  the  glottis  will  prevent  the  instrument  passing  into  the 
larynx,  while,  if  kept  in  the  median  line  and  pushed  carefully  down,  it  will  pass 
into  the  oesophagus.  The  location  of  the  foreign  body  will  be  indicated  by  stop- 
page of  the  sound.  A  proper  use  of  the  radiograph  will  render  all  manipulation 
unnecessary. 

The  prognosis  is  usually  favorable  when  the  occlusion  is  not   complete.     If 
the  distention  is  great  enough  to  interfere  with  respiration,  the  gravity  of  the ' 
accident  is  increased.     Inflammation,  abscess,  and  perforation  of  the  oesophagus 
may  occur  if  the  obstruction  is  not  removed  within  the  first  few  days. 

Treatment. — When  a  foreign  body  is  lodged  in  the  oBsophagus,  and  does  not 
completely  occlude  its  caliber,  it  may  usually  be  dislodged  by  producing  emesis. 


o- 


Fig.  430. — Bristle  probang,  for  removing  foreign  bodies. 


The  ingestion  of  corn-meal  mush  or  a  cereal  mixed  with  cotton 
fiber  has  been  successfully  used,  the  plug  of  cotton  forced  up- 
ward   in   the   act   of   vomiting   dislodging    the    foreign    sub- 
stance.   If  there  is  complete  obstruction,  vomiting  should  not  be  excited,  nor  is  the 
employment  of  a  sound  or  Ijougie  to  push  the  object  into  the  stomach  permissible. 

When  the  substance  lodged  does  not  occlude  the  oesophagus,  and  emesis  has 
failed  to  dislodge  it,  the  umbrella  probang  (Fig.  430)  should  be  introduced. 
This  instrument  is  lubricated,  closed,  and  passed  into  the  oesophagus  until  the 
bristles  are  well  beyond  the  point  of  lodgment,  when  they,  by  pressure  upon  the 
whalebone  handle,  are  projected,  completely  filling  the  tube,  and  the  probang 
withdrawn.  If  the  introduction  of  this  instrument  is  difficult  or  painful,  an 
anaesthetic  should  be  administered. 

In  case  of  complete  obstruction,  where  the  danger  of  inanition  is  threatened, 
or  where  pressure  upon  the  trachea  must  be  relieved,  vesophagotomy  should  be 
performed. 


Fig.  431. — Artificial  plate.     Natural  size. 

Illustrative  Case. — A  man  fifty  3'ears  old  swallowed  an  artificial  plate  of  vul- 
canized rubber  to  which  two  false  upper  incisor  teeth  were  soldered.     This  plate. 


THE   NECK  349 

crescentic  in  shape,  measiired  from  jjoint  to  point  along  the  arch  two  and  a  half 
inches,  the  direct  diameter  l^etween  the  two  points  of  the  crescent  was  one  inch 
and  a  half,  the  widest  measurement  of  the  plate  at  the  center,  including  the  teeth, 
was  five  eighths  of  an  inch  (Fig.  431).  Six  weeks  later  the  foreign  body  was 
located  behind  the  manubrium  by  the  X-ray. 

An  incision  five  and  a  half  inches  in  length  was  made  along  the  anterior 
border  of  the  left  sterno-mastoid  muscle,  extending  one  and  a  half  inches  on  to 
the  surface  of  the  manubrium.  The  fibers  of  the  sterno-hyoid  and  the  sterno- 
thyroid muscles  were  separated  by  dull  dissection,  the  left  lobe  of  the  thyroid 
body  turned  upward,  and  careful  traction  made  on  this  in  order  to  avoid  injury 
to  the  parathyroids  or  overtension  of  the  recurrent  laryngeal  nerve,  which  was 
clearly  seen  as  it  came  from  behind  the  carotid  artery  and  passed  upward  and 
inward  in  the  general  direction  of  the  inferior  thyroid  vessel  of  that  side. 

In  the  exposure  of  the  resophagus  at  this  low  level  very  considerable  care  was 
necessary  to  avoid  injury  to  this  nerve.  A  bougie  was  carried  into  the  resophagus, 
and  on  this  as  a  guide  I  made  an  incision  three  quarters  of  an  inch  in  length 
through  the  gullet  on  its  left  posterior  aspect.  This  was  gradually  dilated  by 
inserting  the  index-finger  which,  carried  down  to  its  full  length,  barely  came  in 
contact  with  the  upper  rim  of  the  plate.  On  the  finger  as  a  guide  a  pair  of  dull- 
pointed  scissors,  curved  on  the  flat,  was  passed  anterior  to  the  plate  and  slightly 
beyond  it.  With  this  on  one  side  and  the  finger  opposing  it,  the  upper  corner 
of  the  plate,  which  was  deeply  imbedded  in  the  walls  of  the  oesophagus,  was  care- 
fully loosened  and  tilted  upward,  and  in  that  way  dislodged  and  l^rought  up  length- 
ways to  the  wound  and  extracted  without  any  further  difficulty.  The  wound  in 
the  cesophagus  was  left  open,  while  the  upper  portion  of  the  superficial  wound 
was  closed  with  four  or  five  silkworm-gut  sutures.  The  deeper  wound  was  filled 
with  a  light  packing  of  sterile  gauze.  There  was  no  vomiting  during  or  after 
the  operation. 

After-treatment. — The  patient  was  placed  in  bed  on  the  back,  the  foot  of  the 
bed  elevated  about  twelve  inches  in  order  to  facilitate  drainage  upward  and  away 
from  the  mediastinum.  Every  four  hours  he  received  six  ounces  of  normal  salt 
solution  by  the  rectum  for  the  first  twentj'-four  hours.  After  this  the  quantity 
was  increased  to  eight  ounces,  and  in  the  intervals  two  nutritive  enemata  were 
given.     He  sufl:ered  practically  no  pain  after  the  operation. 

Kothing  entered  the  cesophagus  for  four  days,  when  a  tube  was  easily  intro- 
duced through  the  mouth  and  oesophagus  and  sixteen  ounces  of  milk  carried  into 
the  stomach.  This  was  repeated  on  the  next  day.  On  the  sixth  day  after  the 
operation  he  began  to  swallow  liquids,  and  of  sixteen  ounces  of  milk  given  four 
ounces  came  out  through  the  wound.  The  proportion  which  leaked  through  grad- 
ually diminished,  and  twelve  days  after  the  operation  the  oesophageal  wound  was 
entirely  healed. 

Colonic  Alimentation' 

The  value  of  alimentation  by  the  colon  in  all  conditions  where  the  upper  por- 
tion of  the  alimentary  canal  requires  absolute  rest  cannot  be  overestimated. 

For  conveying  water  by  the  lower  bowel  to  the  blood,  normal  salt  solution 
should  be  employed  (one  teaspoonful  of  salt  to  one  pint  of  water  which  has  been 
boiled  and  allowed  to  cool  down  to  the  temperature  of  the  body).  From  six  to 
eight  ounces  to  as  much  as  a  pint,  and  at  times  more  than  this,  may  be  employed 
if  absolutely  necessary.  The  foot  of  the  bed  shotdd  be  well  elevated  so  that  the 
liquid  will  gravitate  away  from  the  rectum  and  thus  avoid  jDressure  which  induces 
an  effort  at  evacuation.  When  there  is  intolerance  of  the  lower  bowel  smaller 
quantities  should  be  employed  with  more  frequent  repetition,  or  the  fountain 
syringe  elevated  only  a  few  inches.     (See  General  Peritonitis.) 

Milh  Prepared  by  the  Warm  Process. — One  of  the  most  useful  foods  given  by 
the  colon  is  milk.  When  the  bowel  is  irritable  the  warm  process,  which  is  as 
follows,  should  be  employed:  Put  a  teacnpful  (gill)  of  cold  water  and  the  powder 
contained  in  one  of  the  peptonizing  tubes  (of  Fairchild  Brothers  &  Foster)  into 
a  clean  quart  bottle  and  shake  thoroughly;  add  a  pint  of  cold  fresh  milk  and 


350  THE   NECK 

shake  again;  then  place  the  bottle  in  a  pail  or  kettle  of  warm  water — about  115°  F. 
— or  not  too  hot  to  immerse  the  whole  hand  in  without  discomfort.  Keep  the 
bottle  in  the  water  bath  for  from  thirty  to  forty  minutes  or  longer  if  a  greater 
degree  of  predigestion  seems  necessary,  then  put  it  immediately  on  ice.  As  a  por- 
tion is  needed,  shake  the  bottle,  pour  out  the  quantity — -usually  four  ormces — and 
heat  gently  to  blood  warmth.     Avoid  hasty  heating  and  overheating. 

Six,  eight,  or  twelve  ounces  may  be  given  every  four  or  five  hours,  or  a  larger 
quantity  if  the  case  is  urgently  in  need  of  nutrition  and  the  bowel  is  tolerant. 
In  rectal  feeding  it  is  of  great  importance  not  to  overcrowd  the  colon  sufficiently 
to  produce  irritation. 

Cold  Process. — In  cases  where  the  enema  can  be  retained  for  some  time  without 
irritation,  the  milk  may  be  peptonized  by  the  cold  process.  Put  a  teacupful  (gill) 
of  cold  water  into  a  clean  quart  bottle  and  dissolve  it  by  shaking  thoroughly  the 
powder  contained  in  one  of  the  peptonizing  tubes ;  add  a  pint  of  cold  fresh  milk, 
shake  the  bottle  again  and  immediately  place  it  directly  in  contact  with  the  ice. 

Warm  each  portion  as  it  is  required  for  injection,  being  carefid  to  avoid  hasty 
heating  or  overheating. 

Or,  only  a  sufficient  quantity  to  use  may  be  prepared  each  time  by  the  follow- 
ing method:  In  two  tablespoonfuls  (one  ounce)  of  cold  water  dissolve  one  quarter 
of  the  contents  of  a  peptonizing  tube;  add  eight  tablespoonfuls  (four  ounces)  of 
cold  milk;  warm  to  the  proper  temperature  and  inject  at  once. 

Eggs. — In  administering  eggs  the  following  formula  is  advisable:  Dissolve  the 
white  of  an  egg  in  three  times  its  bulk  of  warm  water;  to  this  add  the  contents  of 
one  of  the  peptonizing  tubes,  stir  well,  and  inject  at  once.  The  water  should  be 
just  warm  enough  to  make  the  mixture  the  proper  temperature  for  the  injection, 
not  hot  enough  to  coagulate  the  albumin. 

Another  method  of  using  the  whole  of  the  egg  is  to  beat  the  white  and  the 
yellow  well  together,  witli  a  pint  of  milk,  adding  a  gill  of  water  in  which  the 
contents  of  a  peptonizing  tube  has  been  dissolved.  It  may  be  employed  cold,  but 
if  it  is  thought  best  to  use  the  warm  method,  warm  water  can  be  used  as  in  the 
formula  immediately  preceding. 

Beef  Juice. — In  using  beef  for  rectal  feeding,  to  a  tablespoonful  of  minced  lean 
beef  add  four  tablespoonfuls  of  cold  water,  and  gradually  heat  to  boiling.  Strain 
all  through  a  fine  sieve  or  colander.  When  it  becomes  lukewarm  add  the  contents 
of  one  of  the  peptonizing  tubes,  and  it  is  ready  for  injection.  More  water  may 
be  added  should  it  seem  desirable. 

Peptonized  Food  and  Whey. — Panopepton  in  rectal  feeding  should  be  diluted 
in  two  or  three  parts  of  lukewarm  water,  or,  preferably,  normal  salt  solution. 

If  it  be  desired  to  employ  whey,  it  can  be  combined  with  panopepton  at  times 
as  follows :  Put  one  pint  of  cold  fresh  milk  in  a  clean  saucepan  and  heat  it  to 
not  over  100°  P.  Add  two  tablespoonfids  of  essence  of  pepsin  and  stir  just  enough 
to  mix.  Let  it  stand  until  firmly  jellied,  then  beat  with  a  fork  until  it  is  finely 
divided,  and  strain.  Warm  to  the  proper  temperature  and  inject  without  dilution. 
Panopepton  and  whey  may  be  used  in  conjunction  by  adding  three  jDarts  of  whey 
to  one  of  panopepton. 

Panopepton  and  jjeptonized  milk  may  be  used  by  mixing  one  tablespoonful  of 
panopepton  with  two  or  three  of  peptonized  milk  prepared  by  the  warm  process. 
Mix  the  panopepton  and  peptonized  milk  when  required  for  use. 

As  a  variation  from  the  foregoing,  the  following  formulas  have  proved  very 
satisfactory :  The  yolk  of  one  egg  whipped  thoroughly  in  one  half  ounce  of  whisky. 
To  this  is  added  one  half  ounce  of  Valentine's  meat  juice  and  four  ounces  of  pep- 
tonized milk.  The  mixture  should  be  warmed  to  about  the  temperature  of  the 
blood  before  being  injected  into  the  colon.  If  whisky  is  not  desired,  use  two  tea- 
spoonfuls  of  Valentine's  meat  juice  thoroughly  mixed  with  the  yolk  of  one  egg 
in  §i]  of  lukewarm  water,  or  normal  salt  solution  gvi,  red  wine,  and  Valentine's 
meat  juice  each  §ss.  and  the  whites  cf  two  eggs. 

Stricture. — Stricture  of  the  ojsophagus  may  be  spasmodic  or  organic.  The 
irritation  caused  by  an  organic  stricture  may  not  only  exaggerate  the  degree  of 


THE   XECK  351 

constriction  by  exciting  spasm  of  the  muscular  fibers  of  this  tube  in  the  immediate 
vicinitT  of  the  stricture,  but  also  at  points  remote  from  the  seat  of  the  organic 
lesion. 

Organic  stricture  is  comparatirely  rare.  It  may  result  from  inflammation  of 
the  oesophagus  caused  by  the  ingestion  of  scalding  water,  strong  acids  or  alkalies, 
the  lodgment  of  foreign  bodies,  by  wounds  of  the  neck,  the  presence  of  a  neoplasm, 
an  aneurism,  or  by  the  local  expression  of  some  general  dyscrasia,  as  in  s}-philis. 

The  diagnosis  is  determined  by  interference  with  deglutition  and  by  physical 
exploration  with  the  btdbous  bougies. 

The  prognosis  is  unfavorable,  although  a  fatal  termination  may  not  be  reached 
for  a  considerable  period. 

The  treatment  consists  in  dilating  the  stricture  by  means  of  elastic  bougies, 
introduced  at  intervals  of  two  or  three  days.  These  instruments  should  be  soft- 
ened by  being  placed  in  warm  water  for  a  few  minutes  before  they  are  used. 
The  mechanism  of  introduction  is  the  same  as  for  the  bulbous  bougies  Just  de- 
scribed. An  extra  long  whalebone  bougie,  after  the  pattern  of  Bankrs  dilating 
urethral  filiform  bougie,  will  prove  of  ser\-ice  in  strictures  of  such  small  caliber 
that  the  ordinary-  oesophageal  bougie  cannot  be  introduced. 

Internal  cesophagotomy  is  a  Justifiable  procedure  in  cases  of  organic  stricture 
which  wiU  not  yield  to  caref vil  and  persistent  efforts  at  dilatation.  In  its  per- 
formance, the  oesophagotome  of  Professor  Sands  (Fig.  432)  has  been  successftilly 
employed.  As  described  by  this  surgeon,'^  the  shank  of  the  instrument,  which  is 
fifteen  inches  and  a  half  in  length  and  four  millimetres  in  diameter,  is  a  flexible 
tube,  made  of  narrow,  spiral  steel  plate,  secured  within  by  two  pieces  of  fine  wire. 


Fig.  432. — Professor  Sands'  oesophagotome. 

in  order  to  prevent  stretching  or  separation  of  the  spiral  coil.  The  instrument 
is  provided  with  a  variable  number  of  steel  bulbs,  each  bulb  being  furnished  with 
a  corresponding  knife  blade.  The  bulb  is  firmly  fastened  by  a  screw  to  the  distal 
end  of  the  shank,  and  the  knife  is  attached  to  an  inner  flexible  steel  rod,  manipu- 
lated by  a  thumbscrew  at  the  proximal  end  of  the  instrument.  By  turning  this 
screw,  the  knife  is  drawn  out  from  its  concealed  position  within  the  bulb,  the  back 
of  the  blade  sliding  over  a  firm  inclined  plane.  An  index  on  a  dial  plate  indicates 
the  amount  of  projection  of  the  blade,  the  maximum  being  two  millimetres  and  a 
half.  A  small  sliding  ring  on  the  spiral  tube  is  used  to  indicate  the  distance  of 
the  stricture  from  the  incisor  teeth.  The  bulb  being  conical,  the  operator  can 
readily  perceive  when  it  comes  in  contact  vrith  the  stricture,  before  he  projects 
the  blade.  In  operating,  a  bulb  must  be  employed  which  exactly  fits  the  stricture; 
the  depth  of  the  incision  will  then  just  equal  the  distance  to  which  the  blade  is 
projected  by  the  action  of  the  screw  in  the  handle.  The  bulb  is  introduced  beyond 
the  stricture,  and  the  instrument  withdrawn  until  the  shoulder  of  the  bulb  indi- 
cates that  it  is  in  contact  with  the  inferior  or  gastric  border  of  the  stricture.  It 
is  then  turned  so  that  the  knife  is  posterior,  the  screw  in  the  handle  which  pro- 
jects the  blade  is  turned  to  the  required  extent,  and  the  constricting  band  divided 
by  pulling  the  instrument  outward  tmtil  resistance  ceases.  The  blade  is  then  con- 
cealed and  the  oesophagotome  withdrawn.  The  dilating  bougies  may  be  introduced 
at  once,  or  this  may  be  postponed  for  twenty-four  hours.  The  danger  to  be 
guarded  against  is  an  incision  through  the  wall  of  the  oesophagus.  With  the 
instrument  of  Prof.  Sands  this  is  scarcely  possible,  especially  when  the  smaller 
bulbs  are  used,  since  the  greatest  projection  of  the  blade  is  only  a  little  more 
than  one  twelfth  of  an  inch. 

When  the  occlusion  is  so  complete  that  the  oesophagotome  cannot  be  employed, 

1  "Xew  York  Medical  Journal."  Febniarv,  1SS4. 


352 


THE   NECK 


or  if  for  any  reason  this  method  of  procedure  is  contra-indicated  and  inanition 
is  threatened,  the  operation  of  gastrostomy  is  imperative.  It  is  not  only  to  be 
commended  in  permanent  occlusion  of  the  cEsophagus  from  stricture,  a  diverticu- 
lum, or  neoplasm,  but  in  those  cases  in  which  extensive  inflammation  has  resulted 
from  the  ingestion  of  corrosive  substances.  In  this  last  condition  the  operation 
is  intended  to  keep  the  organ  at  rest  during  the  process  of  repair,  in  which  nothing 
but  water  is  passed  through  the  cesophagus.  It  is  alwaj's  advisable  to  operate 
early  in  all  conditions. 

Operation. — Two  operative  methods  may  be  entertained.  The  most  modern, 
the  operation  of  Sebanijew  and  Frank,  which  has  met  with  considerable  favor  in 
late  years  and  which  has  for  its  chief  aim  the  establishment  of  a  valvular  fistulous 
opening  for  the  prevention  of  regurgitation  of  food  from  the  stomach,  consists 
of  an  incision,  four  or  five  inches  in  length,  beginning  near  the  xyphoid  appen- 
dix, parallel  with  and  a  little  less  than  two  inches  distant  from  the  costal  cartilages 
of  the  left  side.  All  bleeding  should  be  stopped  as  the  operation  proceeds.  Whe:i 
the  anterior  sheath  of  the  rectus  muscle  is  opened  in  the  line  of  this  incision, 
retractors  are  inserted  and  the  edges  of  the  wound  held  apart.  The  fibers  of  the 
rectus  are  separated  in  their  normal  perpendicular  arrangement  by  a  blunt  in- 
strument, and  the  posterior  sheath  of  this  muscle  and  peritonaeum  are  then  incised 
in  the  same  (perpendicular)  direction.  The  stomach  is  now  drawn  out  through 
this  opening  and  the  silk  suture  passed  through  the  peritoneal  and  muscular  coats 
(not  entering  the  cavity)   at  a  point  near  the  fundus,  which  is  used  in  drawing' 


Fig.  43.3. — Incision  made  and  cone  of  fundus 
of  the  stomach  drawn  out.  A  row  of  sutures 
have  stitched  the  peritonjeum  of  the  abdomi- 
nal wall  and  the  posterior  sheath  Of  the  rectus 
to  the  stomach.     Sebanijew-Frank  method. 


Fig.  434. — The  same  with  the  second  parallel 
incision  made,  skin  raised,  and  stomach 
drawn  through. 


out  a  conical  pouch  of  the  stomach  about  an  inch  and  a  half  in  extent  (Fig.  433). 
At  this  stage  of  the  operation  the  edges  of  the  parietal  peritonaeum,  including  the 
posterior  sheath  of  the  rectus,  are  stitched  carefully  with  fine  silk  to  the  peri- 
toneal surface  of  the  stomach  entirely  around  this  cone,  the  sutures  going  deep  to 
take  good  hold  in  the  muscular  coat.  A  second  incision  an  inch  in  length,  parallel 
to  the  first  and  slightly  above  the  ribs,  is  now  made  through  the  skin.  By  a 
careful  dissection  which  lifts  only  the  integument,  this  wound  is  made  to  com- 
municate with  the  first  incision,  and  the  silk  suture  passed  into  the  stomach  is 
brought  up  underneath  the  loosened  integument  and  out  of  the  last  and  smaller 
incision,  pulling  the  apex  of  the  conical  pouch  of  the  stomach  out  of  this  opening 


THE   NECK 


353 


Fig.  435. — The  operation  completed. 


(Fig.  434).  The  first  incision  is  now  closed  with  silkworm  gut,  and  the  apex 
of  the  cone  of  the  stomach  incised  for  about  half  an  inch  and  sutured  with  fine 
silk  to  the  wound  in  the  integument,  the 
stitches  passing  entirely  through  the  coats  of 
the  stomach  and  the  skin  (Fig.  435). 

The  patient  may  be  fed  at  once  if  the 
condition  demands  it,  but  it  is  usually  safer 
to  wait  for  at  least  twenty-four  hours  in  order 
to  secure  peritoneal  adhesions.^ 

When  operations  for  the  establishment  of 
gastric  fistula  are  undertaken  in  cases  in 
which  there  has  been  oisophageal  stenosis  of 
long  standing,  it  must  be  borne  in  mind  that 
the  stomach  is  always  greatly  contracted,  and 
that  the  fundus  is  lifted  higher  up  toward 
the  diaphragm  than  normal.  In  some  in- 
stances it  is  difficult  to  lift  even  the  fundus 
of  the  stomach  up  to  the  edges  of  the  wound, 
and  the  operation  just  detailed  is  not  prac- 
ticable. 

The  older  method,  which  is  simpler,  re- 
quires exposure -of  the  stomach  by  an  incision 
similar  to  that  described  in  the  foregoing 
operation.  When  a  temporary  fistula  is  re- 
quired it  should  be  preferred  to  the  operation 
of  Frank.  The  stomach  is  immediately  drawn 
into  the  wound  and  sutured  with  fine  silk  to  the  parietal  peritouEeum  and  skin, 
including  the  posterior  sheath  of  the  rectus  muscle,  in  the  entire  circumference 
of  the  wound.  A  continuous  suture  may  be  employed,  although  the  interrupted 
suture  is  generally  used.  This  suture  should  also  include  the  muscular  coat 
of  the  stomach  with  the  serous,  but  should  not  perforate  the  mucous  coat.  Silk- 
worm-gut sutures  may  now  be  inserted  in  the  upper  and  lower  angles  of  the 
incision  in  the  integument,  partially  closing  this  wound.  It  is-  best  not  to 
open  into  the  stomach  until  twenty-four  or  forty-eight  hours  have  elapsed,  by 
which  time  union  will  have  occurred  Ijetween  contiguous  peritoneal  surfaces, 
thus  avoiding  infiltration  into  the  peritonea]  cavity.  Should  the  necessity  for 
nutrition  be  extreme  and  rectal  alimentation  not  to  be  relied  upon  to  sustain 
the  patient,  a  quantity  of  milk  may  be  injected  by  means  of  a  large  aspirating 
needle  into  the  stomach  at  the  point  of  attachment.^  In  several  instances  after 
a  fistula  has  been  established  by  firm  adhesions  I  have  used  an  hour-glass- 
shaped  hard-rubber  nippile  with  a  lumen  of  one  third  of  an  inch  inserted  into 
the  opening,  in  order  to  keep  it  patulous.  A  cork  fitted  to  this  prevented 
regurgitation. 

In  certain  cases  of  stricture  of  the  cesophagus  in  which  only  the  finest  filiform 
bougies  can  be  introduced  it  may  be  found  necessary  to  operate  from  the  gastric 
instead  of  the  pharyngeal  end  of  the  cesophagus.  A  small-sized  bougie  to  which 
a  strong  silk  thread  is  attached  is  carried  into  the  stricture,  through  the  cardiac 
orifice  of  the  stomach  and  brought  out  at  the  mouth,  or  an  opening  in  the  cesopha- 
gus, drawing  the  silk  thread  with  it.     Strictures  have  been  divided  by  a  sawing 

1  This  method  proved  very  satisfactory  in  a  patient  operated  upon  by  the  author  in  1896. 

^  Liquid  or  semisohd  articles  of  food  may  be  introduced  directly  into  the  stomach,  or,  as 
practiced  in  the  remarkable  case  of  Dr.  L.  L.  Staton,  of  North  Carolina,  the  food  may  be  masticated 
and  thus  submitted  to  the  action  of  the  saliva,  and  may  then  be  forced  from  the  mouth  into  the 
stomach  through  a  tube. 

A  woman  about  forty-five  years  of  age  who  came  under  my  observation  had  accidentally 
swallowed  a  corrosive  substance,  producing  acute  closure  of  the  oesophagus.  I  performed  the 
opeiation  of  gastrostomy,  and  through  the  artificial  opening  she  was  nourished  for  about  ten 
months.  An  interesting  feature  of  the  case  was  that  at  the  time  of  the  accident  the  woman  was 
three  months  pregnant,  and  went  to  full  term  and  was  delivered  of  a  healthy  child.  After  the 
acute  inflammatory  symptoms  subsided,  the  strictures  which  resulted  were  successfully  treated 
by  interruijted  dilatation  by  oesophageal  bougies. 


354  THE  NECK 

motion  of  the  string  (Abbe)  or  by  pulling  tliroiigh  a  ^^orios  o{  bulbs  (Maydl), 
gradually  increasing  in  size,  which  are  attached  to  the  string  at  regular  intervals. 
Dr.  Ijauge  has  successfully  employed  tliis  method,  having  a  blade  (cesophagotome) 
attached  to  each  bulb.  The  subsequent  treatment  in  these  cases  consists  of  the 
introduction  of  cosophageal  bougies,  gradually  increasing  in  size.  Of  these  meth- 
ods, that  of  Dr.  Eobert  Abbe  is  to  be  preferred.  For  its  performance,  an  open- 
ing in  the  cesophagus  in  the  neck  is  not  required.  The  sawing  motion  of  the 
thread  divides  the  stricture  and  permits  the  introduction  of  soft  dilating 
bougies. 

X(w  Formation^:. — Epithelioma  is  the  most  common  neoplasm  mot  with  in 
the  esophagus.  Sarcoma  is  rarely  met  with.  Cancer  occurs  usually  between  the 
thirty-fifth  and  sixty-fifth  year  of  life.  The  favorite  location  is  near  the  dia- 
phragm. The  symptoms  of  malignant  growth  are  chiefly  those  due  to  obstruetiou 
and  the  development  of  the  cancerous  cachexia. 

Xon-malignant  neoplasms  are  slower  in  development,  and,  beyond  the  dys- 
phagia they  n\ay  produce,  do  not  atfect  the  general  condition  of  the  patient. 

Trcafmcnt. — ILalignant  new  growths  of  the  oesophagus  always  justify  a  grave 
prognosis,  especially  so  when  situated  in  the  lower  portions  of  this  organ.  Beyond 
palliative  treatment  by  dilatation  with  bougies,  or  gastrostomy  aiter  deglutition 
is  seriously  impaired  or  impossible,  nothing  can  be  done.  Non-uTalignant  neo- 
plasms are  also  not  amenable  to  surgical  interference  when  situated  below  the 
level  of  the  upper  border  of  the  stcrnuni.  When  the  upper  portion  of  the  oesopha- 
gus is  involved,  operation  is  indicated,  not  only  to  relieve  dysphagia,  but  in  the 
effort  to  rojuove  the  disease. 

(Esophagcdomti,  or  exsection  of  a  portion  of  this  organ,  may  occasionally  be 
justified  in  the  removal  of  a  nialignant  growth  of  limitctl  extent  and  sitiwted  in 
the  upper  portion  of  the  tube.  The  probability  that,  before  the  character  of  the 
neoplasm  is  discoverovl.  infiltration  of  the  neighboring  tissues  will  have  occurred, 
almost  precludes  a  favorable  result,  and  is  therefore  a  strong  argument  ag"ainst 
the  propriety  of  the  operation. 

Divcriicuhu  or  pouches  cxmnnunicating  with  the  cavity  of  the  oesophagus  are 
occasionally  observed.  They  may  be  congenital,  but  are  more  frequently  acquired. 
They  communicate  with  the  a^sophagus  usually  on  its  posterior  wall.  Cervical 
oesophageal  diverticula  open  into  the  main  tube  at  the  junction  of  the  ivsophagus 
with  the  pharynx,  whence  the  pouch  uuiy  extend  between  the  vertebral  column  and 
the  esophagus  as  far  down  as  the  bifurcation  of  the  trachea.  Thoracic  esophageal 
diverticula  occur  most  frequently  opposite  the  origin  of  the  bronchi. 

The  causes  of  these  abnormal  pouches  are  various.  As  stilted,  they  may  be 
the  result  of  a  failure  in  normal  development.  A  stricture  of  the  ersophagus  nmy 
lead  to  a  dilatation  and  pouching  of  this  organ  in  that  portion  immediately  above 
the  seat  of  constriction.  .Degeneration  of  the  muscular  fibers  of  the  tube  in  a 
limited  aR^a  may  lead  to  a  hernia  of  the  mucous  membrane,  in  which,  by  the 
impaction  of  ingested  nuitter,  a  diverticulum  is  formed.  Ulceration  of  the  lining 
membrane  at  any  point,  and  froni  any  cause,  may  lead  to  the  development  of  a 
sac  or  pouch  by  the  infiltration  of  ingesta  behind  the  mucous  membrjine.' 

The  diagnosis  of  these  diverticula  is  made  with  great  difiiculty.  and  little  hopie 
of  relief  is  offered,  even  when  the  character  of  the  lesion  is  recognized. 

The  presence  of  the  tumor  is  indicated  by  dysphagia,  and  this  symptom  may 
vary  in  severity  with  the  act  of  deglutition  which  carries  food  into  the  po\ich. 
Dyspnoea  may  be  present  as  the  result  of  pressure  upxin  the  trachea  and  bronchi, 
and  phonation  may  be  interfered  with  if  the  pueumogastric  or  recurrent  laryngeal 
nerves  are  involved. 

The  treatment  is  chiefly  palliatiTe,  and  consists  in  the  nse  of  liquid  diet. 

Fistula  of  the  oesophagus  may  occur  as  a  result  of  a  penetrating  wound,  or 
from  an  abscess  or  ulceration  which  destroys  a  portion  of  the  tvsophagcal  wall. 
A  few  instaiiees  of  supposed  cx>ngenital  fistula  have  been  reported. 

■  RokitanslcN-  has  adv-inced  the  theory  that  thoracic  diverticula  result  fram  atrophy  of  the 
bronchial  hmiphatic  glands,  which  are  situated  on  the  anterior  and  latenil  aspects"  of  the 
ossophagus. 


THE  NECK  355 

The  diagnosis  will  depend  -upon  the  passage  of  ingested  matter  through  the 
outer  opening,  or  the  snccessful  introduction  of  a  probe  from  without. 

Tlie  Irvatment  is  surgical,  and  on  the  same  principle  as  applied  to  all  fistulous 
tracts;  they  should  be  laid  open  by  incision,  packed  to  arrest  bleeding,  and  after- 
ward allowed  to  close  by  granulation.  Or,  as  in  tlie  recent  procedure  for  the  relief 
of  fistula  in  ano,  the  lining  membrane  of  the  fistula  may  be  dissected  away  and 
the  wound  closed  throughout  with  catgut  sutures. 


CHAPTEE    XYIII 
THORAX 

MAMMARY    GLAND ABSCESS    OP    CHEST    WALL EXSECTION    OF    CLAVICLE WOUNDS 

PLEUKA,    LUNGS,   AND   BRONCHI THE   HEART 

Mammary  Gland — Congenital  Defects. — One  or  both  of  these  organs  ma}'  be 
absent;  one  may  develop  fully  while  the  other  remains  in  its  primitive  condition; 
there  may  be  three,  four,  or  five,  the  supernumerary  glands  being  placed  upon  the 
back,  abdomen,  axilla,  or  thigh.^  The  nipple  may  be  absent  or  retracted,  and  may 
be  bifid  or  multiple,  as  many  as  half  a  dozen  occurring  -ndthin  the  limit  of  the 
areola. 

Inflammation  of  the  nij^ple  occurs,  as  a  rule,  in  the  early  period  of  lactation, 
abrasions  produced  by  the  gums  of  the  infant  affording  lodgment  to  septic  organ- 
isms.    Tuberculosis  and  syphilis  may  also  be  acquired  through  these  abrasions. 

The  first  indication  in  treatment  is  to  give  the  organ  rest.  Pain  may  be  re- 
lieved by  emptying  the  milk  ducts  by  artificial  means.  A  child  should  not  nurse 
at  an  infected  nipple  or. breast.  Thorough  cleansing  with  warm  sterile  water  or 
boric-acid  solution  should  be  done  at  frequent  intervals.  When  suppuration  is 
present,  incision  and  drainage  are  essential.  A  circular  shield  should  be  adjusted 
to  prevent  friction  from  the  clotliing. 

All  incisions  should  be  made  in  the  direction  of  the  efferent  ducts  in  lines 
radiating  from  the  nipple. 

Eczema,  or  fissure  of  the  nipple,  is  of  frequent  occurrence  during  lactation. 
It  is  always  annoying,  and  at  times  causes  severe  pain.  Every  source  of  irritation 
should  be  removed.  Boric-acid  solution  is  indicated  in  the  early  stages,  and  later 
glyeerite  of  tannin  or  other  astringent.  Chronic  inflammatory  processes  of  the 
nipple  which  are  intractable,  resisting  all  constitutional  and  local  remedies,  de- 
mand free  incision  and  ablation  of  the  diseased  area. 

Epithelioma  is  the  most  frequent  form  of  malignant  neoplasm  of  the  nipple. 
When  of  recent  growth  and  superficial  in  extent,  Marsden's  jDaste  will  give  the  most 
satisfactory  result.  If  the  deeper  ducts  or  substance  of  the  gland  are  infiltrated, 
the  entire  breast  should  be  removed,  with  the  axillary  glands  and  subjacent  muscles. 

Papilloma,  fibroma,  angeioma,  cysts,  etc.,  may  occur  in  this  organ,  and  should 
be  removed  b}'  the  knife  as  soon  as  discovered. 

Mastitis. — Inflammation  of  the  breast  frequently  follows  infection  of  the  nip- 
ple, the  pathogenic  organisms  traveling  along  the  galactiferous  and  lymphatic 
ducts.  A  single  lobule  or  subdivision  of  the  gland  or  the  entire  organ  may  be 
involved.  In  the  more  severe  forms  of  inflammation  the  process  may  extend  back- 
ward into  the  submammary  tissues  and  axilla. 

Traumatic  mastitis  is  usually  circumscribed,  the  integmnent  and  subcutaneous 
areolar  tissue  being  also  involved.  The  deeper  tissues  escape  unless  great  and 
unusual  violence  has  been  inflicted. 

Non-traumatic  mastitis  is  almost  always  connected  with  lactation,  occurring 
usually  during  the  first  few  weeks  after  parturition.  Mastitis  is  also  a  symptom 
of  parotitis,  although  pyogenic  infection  is  exceedingly  rare  as  a  complication  of 
"  mumps." 

'  The  author  presented  to  the  New  York  Surgical  Society  a  case  in  which  a  supernumerary 
gland  was  situated  in  the  axilla.  The  development  of  this  organ  simultaneously  with  the  normal 
breasts  produced  great  pain  by  pressure  upon  the  branches  of  the  axillary  plexus.  Relief  followed 
extirpation  of  the  abnormal  gland. 

356 


THORAX  357 

Symptoms. — The  first  indications  of  inflammation  of  tlie  mammary  gland  are 
pain  and  localized  induration.  The  pain  is  constant,  and  nsually  severe  in  char- 
acter, and  may  extend  along  the  ribs  to  the  axilla.  It  is  due,  in  great  part,  to 
obstruction  of  the  milk  ducts  and  hyperdistention  from  retained  excretion.  The 
induration  is  usually  well  defined,  and  may  consist  of  one  or  more  nodules.  In- 
jection of  the  skin  is  marked  over  the  area  of  induration.  The  temperature  is  ele- 
vated one  or  two  degrees,  the  jDulse  increased  in  frequency,  and  a  well-pronounced 
chill  or  a  series  of  rigors  is  apt  to  be  a  feature  of  the  earlier  stages  of  this 
disease. 

Treatment. — As  soon  as  infianimation  is  threatened  the  breast  should  be  sup- 
ported by  a  bandage,  or  long,  soft  towel,  or  handkerchief  thrown  around  the  neck 
and  shoulder  and  beneath  the  gland,  holding  it  in  tlie  position  of  least  discomfort. 
In  the  stage  of  hypersemia  the  application  of  a  light  ice-bag,  with  limited  com- 
pression of  the  organ,  is  advisable.  Artificial  means  should  be  employed  to  empty 
the  breast.  It  is  important  to  recognize  the  earliest  collection  of  pus,  and  to 
relieve  it  by  incision.  When  the  induration  is  localized  and  well  marked,  it  is 
good  practice  to  explore  under  cocaine  with  the  large  hypodermic  needle  to  deter- 
mine the  presence  of  suppuration. 

When  abscess  exists  the  pus  should  be  freely  evacuated.  The  incision  should 
be  parallel  with  the  direction  of  the  galactiferous  ducts.  When  the  cavity  is 
opened  the  nozzle  of  the  irrigator  should  be  introduced  and  the  abscess  thor- 
oughly washed  out  with  1-3000  permanganate-of-potash  or  1-5000  sublimate  solu- 
tion. Drainage  should  be  secured,  and  a  loose  dressing  applied.  The  point  of 
incision  should  be  made  in  the  lower  portion  of  the  sac,  so  that  drainage  may  be 
free.  At  times  it  may  be  necessary  to  make  a  counter-opening.  Less  frequently 
aljscess  may  form  in  front  of  the  glandular  tissue  beneath  the  integument  or 
between  the  capsule  of  the  gland  and  the  thorax.  Ostitis  or  ^periostitis  of  the  ribs 
may  be  the  cause  of  deep-seated  submammary  abscess. 

Hypertrophy  of  the  mammary  gland  is  a  physiological  process,  usually  occur- 
ring at  puberty  and  during  pregnancy  and  lactation.  In  rare  instances  there  is 
an  extensive  pathological  hyperplasia  of  the  connective-tissue  elements  of  this  or- 
gan, resulting  in  great  enlargement.  The  diagnosis  may  be  based  upon  the  hard 
character  of  the  mass,  there  being  none  of  the  softness  and  elasticity  which  belong 
to  the  normal  breast.  The  hyperplasia  is  general,  involving  the  entire  framework 
of  the  organ,  which  will  render  it  easy  of  differentiation  from  any  form  of  neo- 
plasm, for  these  grow  from  recognized  centers  of  induration.  The  diagnosis  meets 
with  confirmation  if  the  enlargement  takes  place  after  puberty,  and  in  a  non- 
pregnant woman. 

In  the  treatment  of  this  condition  in  tlie  earlier  stages  well-adjusted  and  pro- 
longed compression  should  be  tried.  This  may  be  effected  by  a  thick  layer  of 
absorbent  cotton  laid  over  the  breast  and  held  firmly  down  upon  it  by  a  roller. 
In  advanced  cases  excision  of  the  organ  is  demanded. 

Tumors  of  the  Breast. — N"ew  formations  in  the  mammary  gland  are  among  the 
more  frequent  surgical  diseases.  Unfortunately,  they  are  more  frequently  malig- 
nant than  benign.  Although  tumors  of  the  breast  occur  chiefly  in  females,  they 
are  not  uncommon  in  males.  Among  the  non-malignant  tumors  are  adenoma, 
jnyxoma,  fibroma,  and  enchondroma.  Various  forms  of  cysts  are  also  met  with, 
while  syphilitic  gumma  and  tubercular  deposits  may  occur  in  this  organ.  Carci- 
noma (scirrhus,  encephaloid,  colloid,  and  epithelioma)  and  sarcoma  are  the  ma- 
lignant neoplasms  which  are  found  in  the  breast. 

Adenoma  of  the  mammary  gland  is  comparatively  rare.  The  pathological 
change,  a  hyperplasia  of  the  glandular  tissue  proper,  is  usually  circumscribed. 
The  tumor  is  of  small  size,  freely  movable  with  the  breast,  and  does  not  form 
adhesions  with  the  capsule,  integument,  or  submammary  fascia.  There  is  no 
inflammatory  process  connected  with  its  development,  no  enlargement  of  the  axil- 
lary glands,  no  dilatation  of  the  veins  of  this  region,  and  little  or  no  pain.  It 
is  found  in  nursing  women,  but  is  also  not  uncommon  in  early  puberty  and  in 
women  who  have  not  borne  children.  It  is  not  the  rule  for  cystic  degeneration  to 
take  place  in  this  neoplasm,  although  such  cysts  may  be  met  with  in  rare  instances 


358  THORAX 

as  a  result  of  degeneration  of  the  new-formed  cells  of  the  deeper  portions  of  the 
growth. 

Adenoma,  of  itself  a  benign  neoplasm,  is  believed  to  be  capable  either  of  de- 
veloping into  carcinoma  or  of  exciting  the  carcinomatous  change  in  the  organ. 
Not  onljr  in  the  simple  circumscribed  form  of  this  neoplasm,  but  in  that  variety 
sometimes  called  tubular  adenoma,  in  which  the  hyperplasia  of  the  glandular 
cells  is  not  confined  to  the  acini  and  terminal  ducts,  but  extends  into  and  involves 
the  galactiferous  ducts  as  far  as  the  nipple,  and  which  is  more  generally  diffused 
than  in  the  simpler  form  above  described,  it  is  admitted  that  the  transformation 
into  carcinoma  is  possible  and  at  times  rapid. 

Treatment. — The  tumor  should  be  excised.  If  it  is  small  it  may  be  removed 
by  sacrificing  only  that  part  of  the  gland  tissue  immediately  around  it.  Upon 
the  recurrence  of  the  growth,  the  entire  breast  should  be  excised. 

In  removing  adenoma  or  other  small  tumor  of  the  breast,  it  may  be  exposed 
by  linear  incision  through  the  skin  and  subcutaneous  areolar  tissue.  As  a  rule, 
this  incision  should  radiate  from  the  nipple  toward  the  circumference  of  the 
breast,  parallel  with  the  galactiferous  ducts.  When  the  tumor  is  well  exposed  by 
retraction  of 'the  edges  of  the  wound  and  subcutaneous  dissection,  it  should  be 
removed,  taking  care  to  go  beyond  the  limit  of  the  disease  about  half  an  inch, 
cutting  through  sound  breast  tissue.  When  the  hajmorrhage  is  arrested,  strong 
subcutaneous  catgut  sutures  should  be  introduced  into  the  breast  tissue  on  either 
side  of  the  space  left  by  removal  of  the  tumor.  When  these  sutures  are  tied,  the 
edges  of  the  wound  in  the  breast  are  approximated,  and  the  depression  which 
otherwise  would  exist  and  cause  a  deformity  is  prevented.  The  edges  of  the 
incision  in  the  integument  should  be  closed  by  a  separate  row  of  sutures. 

When  a  benign  tumor  involves  more  than  half  of  the  breast  it  is  safer  to 
remove  the  entire  organ.  It  is  advisable  not  to  sacrifice  the  nipple  in  these  cases. 
If  the  incision  through  the  skin  be  carried  along  the  fold  or  crease  between  the 
under  surface  of  the  breast  and  the  chest  wall,  the  integument  of  the  breast,  in- 
cluding the  nipple,  may  be  raised  and  the  tumor  and  glands  thoroughly  exposed 
and  removed.  When  the  wound  is  closed,  it  will  be  seen  that  the  scar  is  concealed 
in  this  fold.  Small  tumors  of  this  nature  occupying  the  lower  half  of  the  breast 
may  easily  be  removed  through  this  incision,  leaving  no  visible  sear. 

Myxoma  is  very  rarely  met  with  in  the  mammary  gland.  It  may  occur  as  a 
single  nodule  and  develop  slowly  from  a  single  center,  or  it  may  develop  from 
several  centers  and  rapidly  invade  the  entire  organ.  It  is  not  adherent  to  the 
skin  until  inflammatory  adhesions  occur  preliminary  to  ulceration  of  the  mass. 
Infiltration  of  the  axillary  glands  occurs  only  as  a  result  of  inflammation.  The 
nipple  is  not  retracted. 

The  prognosis  is  favorable  if  the  tumor  is  discovered  early  in  its  development, 
and  if  in  the  excision  a  suificient  portion  of  healthy  tissue  is  removed  with  the 
neoplasm.  The  treatment  is  free  excision.  The  entire  gland  should  be  sacrificed, 
and,  if  the  organ  is  wholly  involved,  the  line  of  incision  should  be  well  out  from 
the  limits  of  the  tumor  in  the  healthy  tissues. 

Fibroma  of  the  mammary  gland  may  occur  at  any  period  of  life.  It  is  rarer 
in  the  aged  than  in  the  young,  occurring  mostly  in  persons  under  forty,  and  occa- 
sionally under  puberty.  This  form  of  connective-tissue  hyperplasia  may  affect 
the  entire  organ  (as  in  general  hypertrophy,  already  descril^ed)  or  a  circumscribed 
area.  A  nodular  or  circumscribed  fibroma  is  a  hard,  dense  tumor,  freely  movable 
with  the  gland,  and  may  or  may  not  be  painful.  Shrinkage  of  the  breast  occurs 
at  times  as  a  result  of  the  cicatricial  contraction  of  the  new-formed  tissue,  and, 
when  near  the  nipple,  its  retraction  may  resemble  that  of  scirrhus.  As  a  rule, 
this  variety  of  tumor  is  of  slow  development.  Not  infrequently  it  undergoes  cystic 
degeneration.  The  axillary  glands  are  not  involved,  nor  do  adhesions  occur  until 
after  atrophy  of  the  gland  with  retraction  of  the  new-formed  connective  tissue. 
It  should  be  removed  by  the  same  wide  and  free  excision  as  recommended  for 
myxoma. 

Encliondroma  of  the  breast  is  very  rare.  It  is  apt  to  be  circumscribed.  Cal- 
cification has  been  observed  in  some  of  the  few  recorded  cases  of  this  neoplasm. 


THORAX  359 

Occasionally  it  is  found  with  carcinoma.  Encliondronia  of  the  breast  should  be 
freely  excised. 

Cysts. — Among  the  forms  of  cystic  tumors  found  in  this  gland  are  galactocele, 
sanguineous,  dermoid,  and  hydatid  cysts,  and  the  forms  which  occur  in  the  degen- 
eration of  adenoma,  fibroma,  myxoma,  and  carcinoma. 

Galactocele  is  a  cyst  caused  by  obstruction  of  the  ducts  which  convey  the  milk 
toward  the  nipple.  The  obstruction  is  followed  by  distention  of  the  tubes  and 
acini.  Examined  with  the  microscope,  the  contents  of  these  cysts  consist  of  epi- 
thelial cells  in  various  stages  of  granular  metamorphosis,  and  milk  globules. 

The  diagnosis  may  be  determined  by  aspiration.  The  treatment  consists  in 
incision  and  evacuation  of  the  contents  with  drainage  until  the  cysts  may  be 
obliterated  by  the  process  of  granulation. 

Dermoid  and  hydatid  cysts  are  exceedingly  rare  in  this  situation.  The  diag- 
nosis may  be  determined  by  aspiration,  and  the  proper  treatment  is  excision. 
Cysts  may  occur  in  the  breast  from  the  extravasation  of  blood  after  contusions, 
or  from  the  non-traumatic  rupture  of  blood  or  Ijrmph  vessels.  They  heal  readily 
after  incision  and  drainage. 

Tuberculosis  of  the  breast  is  rare.  It  is  probably  due  to  infection  through  the 
nipple.  The  nodules  may  be  disseminated  generalh'  through  the  gland  or  beneath 
the  capsule,  or  there  may  be  one  or  more  large  collections.  They  are  hard  to  the 
touch.  The  history  of  the  case  will  aid  in  determining  the  character  of  the  lesion. 
If  there  is  no  general  dissemination  of  tubercular  matter — that  is,  if  the  disease 
is  limited  to  the  mammary  gland — this  organ  should  be  freely  excised. 

Sarcoma  of  the  breast  attacks  usuallj'  the  young  and  middle-aged.  It  is  rarely 
general  in  its  development,  but  commences  as  a  single  nodule,  more  apt  to  occupy 
the  upper  portion  of  the  organ  than  the  lower,  whence  it  invades  the  gland  and 
circumjacent  structures  in  every  direction.  The  rapidity  with  which  it  grows 
depends  in  part  upon  the  microscopical  character  of  the  neoplasm,  and  in  part 
upon  the  age  of  the  patient.  Sarcoma  develops  more  rapidly  in  the  young,  and  the 
round-cell  variety,  which  is  most  frequently  met  with  in  the  breast,  is  more  rapid 
in  its  development  than  the  spindle-cell  sarcoma.  In  the  earlier  stage  this  tumor, 
though  firm  and  nodular,  is  freely  movable  with  the  gland.  Its  growth,  however, 
is  often  so  rapiid  that  the  skin  and  subcutaneous  tissues,  the  submammar}'  fascia, 
and  the  muscles  of  the  chest  become  involved,  the  breast  stands  out  full  and  tense, 
and  becomes  immovable.  The  superficial  veins  are  greath^  enlarged.  As  a  rule, 
the  lymphatic  glands  of  the  axilla  are  not  involved  until  infection  and  suppuration 
of  the  mass  induces  axillary  adenitis. 

Differentiation  between  round  and  spindle-cell  sarcoma  is  difiicult  unless  the 
tumor  is  examined  with  the  microscope.  Practicall}',  the  differentiation  is  not 
important.  The  first  variety  is  softer  to  the  touch,  more  rapid  in  growth,  and  is 
more  vascular.     It  is  apt  to  occur  in  the  younger  class  of  patients. 

Both  forms  of  sarcoma  tend  to  the  formation  of  cysts  within  their  structure. 
As  stated,  they  may  be  due  to  fatty  degeneration  of  the  embryonic  elements  of 
the  tumor,  or  may  result  from  caverns  of  blood  which  have  become  cut  off  from 
the  general  circulation  through  the  new  growth. 

The  diagnosis  depends  upon  the  age  of  the  patient,  the  rapidity  of  develop- 
ment, and  the  absence  of  axillary  engorgement.  The  treatment  consists  in  free 
excision.  The  action  of  pj'ogenic  and  erysipelatous  organisms  upon  sarcoma  will 
be  given  in  the  chapter  on  timiors. 

Carcinoma  is  by  far  the  most  common  form  of  neoplasm  met  with  in  the  breast. 
The  order  of  prevalence  of  the  four  varieties  is  scirrhus,  enceplialoid,  colloid,  and 
epithelioma.  Cancer  of  the  mammary  gland  occurs  in  rare  instances  in  males. 
In  women  it  is  met  with  most  frequently  in  the  period  from  the  fortieth  to  the 
sixtieth  years  of  life.  It  may  occur  later  than  this,  and  is  rarely  seen  earlier  than 
the  age  of  thirty.  Women  who  have  never  been  pregnant  are  affected,  though  prob- 
ably not  so  liable  as  those  who  have  borne  children. 

Scirrhus  of  the  breast  appears  usually  as  a  single  hard  nodule  or  lump,  situ- 
ated in  the  substance  of  the  gland,  movable  with  this  organ,  but  firmly  imbedded 
in  it;  or  two  or  more  nodules  may  appear  simultaneously  in  different  parts  of  the 


360  THORAX 

gland,  which  eventually  approach  each  other  so  as  to  form  a  nodulated  mass.  The 
growth  of  scirrhus  is,  as  a  rule,  not  rapid  in  the  earlier  stages  of  its  development, 
but,  after  reaching  a  certain  size,  it  spreads  with  increasing  rapidity.  The  length 
of  time  which  may  elapse  between  the  commencement  of  the  neoplasm  and  metas- 
tasis in  the  subpectoral  and  axillary  lymphatics  varies  in  different  individuals.  It 
is,  however,  in  general  proportionate  to  the  rapidity  of  the  growth  of  the  neoplasm. 
Pain,  which  is. a  symptom  of  this  disease,  is  lancinating  in  character  rather  than 
dull  and  continuous.     It  is  usually  more  severe  in  tumors  which  develop  rapidly. 

Cancer  of  the  breast  may  assume  the  form  of  a  single  large,  rounded,  and  nodu- 
lar mass,  or  nodules  of  various  sizes  may  develop  in  the  organ  or  be  scattered  in 
knots  or  groups  beneath  the  integument,  in  the  pectoral  muscles,  or  along  the 
line  of  lymphatics  leading  into  the  axilla.  If  left  unmolested,  scirrhus  soon  in- 
vades the  tissues  around  the  breast,  the  muscles  of  the  chest  becoming  infiltrated, 
the  skin  attached  to  the  mass,  and  the  nipple  retracted.  On  account  of  pressure 
the  circulation  in  the  most  remote  portions  of  the  invaded  gland  is  interfered 
with,  and  ulceration  ensues,  giving  rise  to  a  more  or  less  extensive  granulating 
surface,  from  which  there  is  a  discharge  of  a  serouslike  fluid  containing  blood- 
corpuscles,  embryonic,  pus,  and  cancer  cells.  In  the  later  stages  lymphatic  en- 
gorgement is  more  extensive,  and  the  effects  of  compression  upon  the  thoracic  and 
axillary  nerves  more  evident.  Not  infrequently  the  subclavicular,  supraclavicular, 
and  cervical  lymphatics  become  engorged.  Pressure  symptoms  are  not  alone  con- 
fined to  the  nerves,  but  the  interference  with  the  return  circulation  in  the  axillary 
vein  may  produce  general  oedema  of  the  extremity. 

Encephaloid  cancer  of  the  breast  differs  only  in  degree  from  the  scirrhus 
variety.  It  is  softer  under  pressure,  grows  with  much  greater  rapidity,  ulcerates 
earlier  and  more  extensively,  is  more  prone  to  hsemorrhages,  and  tends  to  a  more 
rapidly  fatal  termination.     It  is  more  apt  to  recur  after  removal. 

Epithelioma  of  the  breast  is  rare.  It  commences  in  or  near  the  nipple,  and 
ma}'  extend  along  the  epithelial  lining  of  the  lactiferous  ducts,  or  spread  along 
the  integument  of  the  areola.  Although  ulceration  begins  earlier,  its  progress  is 
slower  and  less  painful  than  in  either  of  the  forms  of  cancer  just  given,  which 
attack  the  deeper  structures  of  the  gland.  If  not  extirisated,  the  entire  gland  may 
be  infiltrated,  metastasis  occurs,  and  death  follows  from  general  exhaustion. 

Prognosis  and  Treatment. — The  prognosis  of  cancer  of  the  breast  is  always 
grave,  the  gravity  varjdng  with  the  character  of  the  neoplasm,  the  general  condi- 
tion of  the  patient,  and  the  length  of  time  the  tumor  has  existed  before  excision. 
Left  without  surgical  interference,  a  fatal  termination  is  reached  usually  within 
one  to  two  years  after  the  appearance  of  the  disease.  Encephaloid  is  most  rapidly 
fatal,  scirrhus  next  in  order,  and  epithelioma  last.  Death  ensues  from  exhaustion 
caused  by  toxasmia,  suppuration,  pain,  anorexia,  and  infiltration  of  the  various 
organs  by  metastasis.  In  isolated  cases  scirrhus  of  the  breast  reaches  a  certain 
point  and  remains  stationary  for  a  number  of  years  before  again  enlarging  and 
producing  a  fatal  issue. 

With  the  operation  as  performed  in  modern  practice  the  iDrognosis  is  much 
more  favorable.  This  implies  early  recognition  of  the  presence  and  character  of 
the  neoplasm,  immediate  and  wide  extirpation  of  the  invaded  organ,  and  a  careful 
dissection  of  all  metastatic  foci  in  the  glands  of  the  axillary  plexus.  As  to  the 
selection  of  cases  in  which  operation  is  justifiable,  it  is  imperative  in  all  cases  in 
which  the  lymphatic  engorgement  has  not  extended  beyond  the  axillary  region, 
and  in  which  the  invasion  of  the  pectoral  and  thoracic  muscles  is  not  so  deep 
or  extensive  that  a  clean  excision  is  possible  without  opening  into  the  thorax. 
Even  when  metastasis  of  the  cervical  lymphatics  has  occurred,  relief  may  be  ob- 
tained. It  is  well  to  bear  in  mind  that  a  simple  non-malignant  enlargement  of 
the  glands  may  occur  before  true  metastasis  has  taken  place. 

Treatment. — It  is  advisable  to  prepare  the  patient  as  if  the  most  radical  pro- 
cedure were  intended,  but  when  the  diagnosis  is  uncertain  to  incise  the  tumor. 
At  times  cysts  with  thick  walls  or  when  tense  from  overaccumulation  may  be 
mistaken  for  malignant  neoplasms.  If  the  suspicion  of  malignancy  is  confirmed 
the  incision  shoukl  be  tightly  packed. 


THOR.\X  361 

In  general,  the  foUo-n-ing  rule  of  practice  is  submitted: 

A  tumor  of  ilie  breast  occurring  in  either  sex  after  the  thirtieth  year  of  life 
should  be  excised  as  soon  as  discovered.  The  contra-indieations  to  this  procedure 
are:  (1)  a  condition  of  prostration  so  extreme  that  a  surgical  operation  would 
involve  great  and  unusual  risk  to  life;  {2)  metastasis  to  such  an  extent  that  com- 
plete removal  of  the  neoplasm  is  impossible. 

The  incision  and  dissection  should  be  far  away  from  the  limit  of  the  tumor  in 
the  healthy  tissues.  When  only  a  small  portion  of  the  organ  is  involved,  it  is 
advisable  to  extirpate  the  entire  gland.  When  the  patient  is  under  thirty  years 
of  age,  and  when  the  tumor  is  thoitght  to  be  benign  in  character,  the  less  radical 
operation  of  enucleation  of  the  neoplasm  may  be  undertaken.  Any  new  formation 
so  removed  should  be  carefttlly  examined  at  once,  and,  if  found  to  be  malignant, 
the  radical  extirpation  completed  at  this  operation. 

Operation. — The  patient  is  placed  upon  the  table  with  the  chest  slightly  ele- 
vated, the  breast  and  axilla  of  the  affected  side  near  the  edge.  The  arm,  entrusted 
to  an  assistant,  should  be  held  at  a  right  angle  to  the  body,  and  the  head  directed 
to  the  opiposite  side.  Extreme  elevation  of  the  arm  may  overstretch  the  nerve 
trunks  and  cause  paralysis. 

In  removal  of  the  mammary  gland  for  cancer,  two  important  points  present 
themselves  to  the  surgeon,  first  and  most  important  is  that  the  operation  be 
done  at  the  earliest  possible  moment.  If  this  were  properly  done  within  the  first 
two  to  four  months  in  every  ease  of  neoplasm  of  the  breast,  few  wotdd  perish, 
where  a  great  man}^  are  sacrificed  by  delay. 

Secondly,  and  of  equal  importance,  the  operation  should  be  thoroughly  done. 
It  is  as  important  to  remove  the  entire  hTuphatic  apparatus  from  the  clavicle 
through  the  axillary  space  down  to  and  with  the  breast  as  it  is  to  remove  the 
breast  itself.  It  is  very  exceptional  when  metastases  have  not  occurred  in  the 
hinphatics  of  the  pectoralis  minor  and  axilla,  if  a  tumor  has  existed  in  the  breast 
for  tn-o  or  three  months.  The  glands  in  the  neck  should  also  be  examined  and 
removed  when  involved. 

Xo  special  incision  will  apply  to  all  cases.  It  should  always  be  well  awaj' 
from  am'  suggestion  of  cancerous  infiltration.  When  the  neoplasm  is  of  moderate 
size  and  is  deeply  situated  in  the  breast  substance,  the  skin  as  yet  not  being  in- 
volved and  freeh'  movable,  nor  the  nipple  well  retracted,  the  operator  can  afford 
to  leave  a  larger  margin  of  skin  for  the  purpose  of  covering  up  the  wound  than 
under  other  conditions.  When  the  mass  is  of  considerable  size,  or  is  superficially 
located,  and  when  the  nipple  is  retracted  and  the  skin  infiltrated  for  one  or  two 
inches  on  either  side  of  the  center  of  induration,  it  is  advisable  to  go  two  or  three 
inches  in  all  directions  from  the  edges  of  induration.  Fig.  4-36  (J.  Collins  War- 
ren) fairly  represents  the  extent  of  this  incision.  When  it  becomes  necessary  to 
remove  the  infiltrated  glands  from  the  supraclavicular  regions,  a  perpendicular 
cut  coming  from  the  neck  and  crossing  the  clavicle  shotdd  be  added  to  the  inci- 
sion given  in  the  illustration.  The  posterior  curved  incision  there  shown  is  not 
always  essential;  it  is  only  used  when  so  much  of  the  integument  over  the  breast 
proper  has  of  necessitj'  been  removed  that  a  plastic  or  sliding  operation  is  neces- 
sary to  cover  in  the  gap.  Xo  manipulation  of  the  breast  should  be  permitted,  for 
fear  of  forcing  cancer  cells  into  the  l^-mphatics.  As  soon  as  the  skin  is  divided 
it  is  advisable  to  closely  remove  the  subcutaneous  fat,  working  always  as  far 
away  from  the  tumor  as  possible,  through  an  entirelj'  healthy  zone.  After  the 
incision  has  been  outlined  and  made  through  the  skin,  the  dissection  should 
commence  in  all  cases  at  the  clavicle  (Fig.  436  a).  As  a  rule  there  is  no  super- 
ficial infiltration  in  this  region,  and  the  incision  may  be  made  in  such  a  way  that 
after  the  dissection  is  completed  the  skin  readily  comes  together.  The  essential 
point  to  be  borne  in  mind  is  that  the  contents  of  the  axilla  and  the  pectoral 
muscles  must  be  well  exposed.  The  incision  most  commonly  adopted  is  one  which 
begins  at  the  point  of  insertion  of  the  tendon  of  the  pectoralis  major  muscle  into 
the  humerus,  curved  slightlj'  inward  in  a  direction  which  will  go  wide  of  the  edge 
of  the  tumor  and  around  the  breast,  describing  a  circle  which  meets  with  the  first 
portion  of  the  incision.    A  second  incision  is  made  from  above  the  center  of  the 


362 


THORAX 


clavicle  and  joins  this  at  a  right  angle,  when  it  becomes  necessary  to  remove  any 
infiltrated  glands  in  the  supraclavicular  region.  The  surgeon  should  see  tJiat  the 
cephalic  vein  is  not  endangered.  HEenjorrhage  is  arrested  in  the  line  of  incision 
as  the  operation  proceeds    (Fig.  436a).     The  flap  in  the  upper  portion  of  the 


Fig.  436. — General  plan 


pectoral  muscles 


dissection  is  stripped  of  fat,  leaving  nothing  hut  the  skin,  and  this  is  reflected  out 
of  the  way.  The  flap  in  the  axilla  is  lifted  in  the  same  way,  being  freed  from 
fat,  keeping  the  scissors  or  knife  close  to  the  under  surface  of  the  integument, 
and  is  reflected  downward.     The  pectoral  muscles  are  exposed  and  the  upper  and 


Fig.  436a. — The  same,  showing  the  method  of  hsemostasis  as  the  axilla  is  being  cleared. 
(J.  Collins  Warren.) 

most  important  portion  of  the  field  of  operation  is  in  view.  The  pectoralis  major 
muscle  should  be  separated  from  the  humerus  through  its  tendon  and  close  to 
the  point  of  insertion.  (In  the  case  of  a  small  tumor  with  limited  infiltration  of 
the  lymphatics,  the  clavicular  portion  of  the  pectoralis  major  may  be  left.     The 


THORAX 


363 


thoracic  portion  and  the  pectoralis  minor  should  always  be  removed.)  (Fig.  -ioGa.) 
This  can  safely  be  done,  since  the  finger  can  be  inserted  between  it  and  the  ves- 
sels of  the  axilla  to  serve  as  a  guide  to  its  division.  This  muscle  is  then  reflected 
to-nrard  the  chest.  The  operator  now  carefully  removes  that  portion  of  the  pec- 
toralis major  muscle  which  is  attached  to  the  clavicle  immediately  over  the  point 
where  the  axillary  artery  and  vein  rest  under  this  bone.  This  accomplished,  and 
all  hemorrhage  arrested  by  the  application  of  forceps  and  ligatures  when  re- 
quired, with  the  greatest  care  the  operator  strips  all  the  fat,  lymphatics,  and 
loose  tissue  from  the  fascia  of  the  axillary  vein  and  artery,  tving  with  fine  silk 
the  venous  branches,  which  must  be  divided  usually  within  one  eighth  to  one 
fourth  of  an  inch  of  the  point  of  entrance  into  tlie  parent  trunk.  When  the 
pectoralis  minor  muscle  is  reached  in  the  dissection,  its  insertion  into  the  cora- 


FiG.  4366. — The  same,  after  the  sutures  have  been  inserted.     A  (.-igarette  gauze  or  catgut  drain  should 
be  placed  in  the  lower  angle  of  the  wound  nearest  the  back.     (J.  Collins  Warren.) 


coid  process  should  be  divided,  and  it  in  turn  reflected  inward  toward  its  point  of 
origin  from  the  chest.  The  dissection  is  then  continued  down  the  vein  and  artery 
until  the  lower  botmdary  of  the  axilla  is  reached.  At  this  stage  of  the  operation 
it  is  well  to  pack  the  wound  with  sterile  gauze.  Then,  beginning  from  above 
downward,  the  connective  tissue  and  h-mphatics  which  rest  upon  the  chest  wall 
and  the  under  surface  of  the  pectoralis  minor  muscle  are  carefully  removed,  di- 
viding the  small  pectoral  muscle  well  out  toward  its  origin.  The  upper  fibers 
of  the  pectoralis  major  are  removed  in  the  same  way.  and,  lastly,  the  lower  por- 
tion of  the  pectoralis  major  is  dissected  from  the  ribs,  and  with  it  the  breast, 
which  still  remains  attached.  Wlien  the  axillary  vein  is  studded  with  infected 
h"mphatics  this  vessel  should  be  tied  at  the  clavicle  and  entirely  removed  with 
all  of  its  branches.  The  danger  of  seriously  wounding  the  axillary  vein  is  not 
great  When  in  the  course  of  the  dissection  a  branch  coming  into  this  vein  is 
wotmded  close  to  the  parent  trunk,  the  stump  of  the  branch  may  be  grasped  with 
an  Esmareh  forceps  and  a  fine  silk  or  linen  ligature  tied  around  it  on  a  level  with 
the  wall  of  the  vein.    By  taking  care  not  to  injure  the  cephalic  vein  in  the  primary 


364 


THORAX 


incision,  this  vessel  will  carry  on  the  eixenlation  in  the  arm  even  after  the  axillary 
is  obliterated.  Silk  should  be  used  in  preference  to  catgut  for  this  particular 
ligature.  In  cleaning  out  the  axilla,  the  dull-pointed  scissors,  or  dulled  grooved 
director  will  be  found  the  most  suitable  instruments.  In  closing  this  wound,  the 
upper  portions  of  the  flap  fall  easily  together,  and  by  bringing  the  arm  down 
to  or  slightly  upon  the  chest,  and  sliding  a  broad  skin  flap  from  the  chest  wall, 
the  large  space  left  by  removal  of  the  breast  may  be  in  great  measure  closed. 
Any  raw  surface  left  should  heal  by  granulation,  but  may  ultimately  have  to  be 
closed  by  grafting. 

After  the  entire  pectoral  muscles  have  been  removed,  the  clavicular  fibers  of 
the  deltoid  enable  the  arm  to  be  carried  across  the  chest. 

In  uniting  the  flaps  (Fig.  436&),  silkworm  gut  is  the  best  suture.  It  is 
advisable  to  carry  a  good-sized  catgut  drain  out  of  the  lowest  portion  of  the  axilla 


^      C7a^ 

Inrui  Pqt  tun  y  PedorviS 
Cut      "       > 


Fig.  436c. — The  supraclavicular  dissection.      (J.  Collins  Warren.) 


through  the  skin,  to  give  escape  to  any  oozing.  The  dressings  often  require  to 
be  changed  on  the  second  or  third  day. 

When  it  becomes  necessary  to  extirpate  the  infiltrated  cervical  glands  this 
should  be  done  as  sho'wn  in  Fig.  436  c. 

Ahscess  of  the  thoracic  walls  usually  results  from  ostitis  of  the  clavicle,  ster- 
num, ribs,  scapula,  or  vertebrse,  or  enchondritis  of  the  costal  cartilages  of  tuber- 
culous origin.  If  not  incised,  it  opens  spontaneously  through  the  integument  and 
discharges  pus  and  at  times  particles  of  bone  and  other  detritus.  Spontaneous 
cure  may  occur,  although  this  is  the  exception.  Sinuses  usually  result,  and  con- 
tinue until  the  diseased  tissues  are  excised.  The  most  common  seat  of  ostitis  is 
in  the  sternum  and  the  sternal  ends  of  the  ribs.  The  indications  in  treatment 
are  to  lay  the  sinuses  open,  carefully  following  each  to  its  terminus,  scrape  the 
indurated  lining  membrane  away  with  the  scoop,  and  remove  all  dead  bone  by 
scraping  with  the  Volkmann  spoon  or  exsection  in  mass.  Opening  into  the  pleura 
or  mediastinum  should  be  avoided.  Wlren  the  abscess  leads  behind  the  sternum 
a  segment  of  this  bone  should  be  removed  in  order  to  expose  and  drain  the  cavity. 


THORAX  365 

In  exsection  of  a  portion  of  one  or  more  ribs,  the  incision  should  he  made  along 
the  center  of  the  bone,  the  periosteum  lifted  with  the  elevator  first  from  the 
anterior  surface  and  then  from  behind,  taking  great  care  not  to  enter  the  pleural 
cavity,  and  the  bone  divided  with  the  cutting  forceps.  All  of  these  wounds  should 
be  packed  with  gauze. 

Exsection  of  the  clavicle  may  be  demanded  in  ostitis  of  this  bone.  In  a  case 
operated  upon  by  myself  for  necrosis,  the  incision  extended  the  entire  length  of 
the  bone,  and  the  excision  was  subperiosteal  throughout.  A  new  and  strong  clavicle 
'formed,  with  perfect  motion  at  the  sternal  and  acromial  articulations.  The  short- 
ening was  half  an  inch.  Six  years  after  the  operation  the  function  of  the  injured 
side  was  perfect. 

Wounds  of  the  Chest 

Wounds  of  the  chest  are  divided  into  penetrating  and  non-penetrating.  A 
penetrating  wound  is  one  which  opens  into  the  pleural  cavity  or  mediastinum. 
Pneumothorax,  with  hajmorrhage  into  the  pleural  sac,  may  occur,  however,  with- 
out an  external  opening,  as  when,  after  a  contusion  of  the  chest,  a  fractured  rib 
penetrates  the  lung,  the  inspired  air  filling  the  pleural  cavity  and  causing  collapse 
of  the  lung. 

Contused  wounds  of  the  chest  maj^  be  accompanied  by  fracture  of  the  ribs, 
lacerations  of  the  muscles,  or  followed  by  pleuritis  with  or  without  either  of  the 
above  complications. 

Xon-penetrating  wounds  of  the  chest,  whether  incised,  lacerated,  or  punctured 
are  treated  as  directed  for  such  lesions  in  other  parts  of  the  body.  The  same 
may  be  said  of  gunshot  wounds  which  do  not  involve  the  bony  framework  of  the 
thorax  or  pass  into  the  cavities. 

Penetrating  wounds  of  the  thorax  are  dangerous  in  proportion  to  the  size  of 
the  entering  substance  and  the  organs  invaded. 

Punctured  wounds,  not  involving  the  heart,  great  vessels,  bronchi,  trachea,  and 
oesophagus  are  not  usually  fatal,  while  death  is  apt  to  follow  even  small  lesions 
of  these  organs.  Incised  wounds  are  more  dangerous,  while  gunshot  wounds  are 
still  graver  lesions. 

Passing  in  any  direction  into  or  through  the  mediastinum,  a  gunshot  wound 
is  apt  to  inflict  fatal  violence.  In  the  lungs  and  pleurse  the  prognosis  is  not  so 
grave,  being  proportionate  to  the  size  or  shape  of  the  missile  and  to  the  nearness 
of  its  approach  to  the  great  vessels  at  the  root  of  the  lung. 

Again,  if  a  rib  is  fractured  at  the  point  of  entrance,  the  gravity  of  the  prog- 
nosis is  increased  from  the  destruction  by  and  the  lodgment  of  particles  of  bone 
driven  into  the  lung.  Wounds  produced  by  round  missiles  of  small  caliber,  not 
fatal  within  a  few  hours,  are  apt  to  end  in  recovery  unless  an  uncontrollable  sepsis 
is  established.  Conical  missiles  which  strike  the  chest  wall  and  turn  or  "  plunge  " 
on  their  long  axes  produce  extensive  and  usually  fatal  injury. 

Surgery  of  the  Pleura^  Lungs,  and  Bronchi. — Inflammation  of  the  serous  mem- 
brane covering  the  lungs  and  lining  the  inner  surface  of  the  thoracic  cavity  may 
result  from  infection  primarily  in  the  lung  (tuberculosis,  pneumonia,  foreign  body, 
etc.);  from  the  costal  side  by  contact  with  ostitis  of  a  rib,  the  sternum,  or  ver- 
tebra; from  an  abscess  of  the  liver  or  spleen  (subphrenic)  or  any  subdiaphrag- 
matic infection;  from  a  traumatism  with  or  without  fracture  of  a  rib;  not  infre- 
quently from  the  end  of  a  broken  rib  driven  through  the  pleura  into  the  lung ;  and 
lastly  pleuritis  may  occur  from  infection  through  the  general  circulation. 

As  the  result  of  pleuritis  there  frequently  collects  an  accumulation  of  serum 
or  pus  either  in  the  general  pleural  cavity  or  in  an  isolated  portion  (encapsulated) 
which  may  require  evacuation. 

This  should  be  done  by  careful  aspiration  as  soon  as  even  a  small  accumulation 
has  been  recognized.  In  using  this  instrument  every  precaution  should  be  taken 
to  prevent  puncture  of  the  lung,  which  is  always  apt  to  be  followed  by  pneumo- 
thorax with  infection. 

A  short  hypodermic  needle  should  be  used  to  demonstrate  the  presence  of  fluid, 
gauging  carefully  the   depth  to   which   the  needle  penetrates   when   the   fluid   is 


366  THORAX 

reached.  A  trocar-eamila  should  then  be  introduced  to  the  same  depth,  -with- 
drawing the  trocar  as  soon  as  the  instrument  is  felt  to  enter  the  cavity.  Bj^  taking 
this  23recaution,  as  the  fluid  escapes  and  the  lung  finally  comes  in  contact  with 
the  instrument,  no  puncture  can  be  made.  The  fenestrated  canula  should  be  used. 
As  much  of  the  fluid  should  be  withdrawn  as  will  be  tolerated  by  the  patient,  the 
degree  of  toleration  being  determined  by  the  condition  of  the  patient's  pulse  or 
any  suggestion  of  collaj)se.  When  a  large  quantity  has  accumulated,  compressing 
the  lung  and  displacing  the  heart  from  its  normal  position,  it  is  not  safe  entirely 
to  empty  the  cavity  at  one  sitting,  since  death  has  followed  in  several  instances- 
from  this  procedure. 

If  the  fluid  withdrawn  is  serum,  containing  no  pus,  nothing  further  should 
be  done  except  to  carefully  seal  the  puncture  through  the  skin  by  a  bit  of  sterile 
gauze  and  adhesive  plaster.  The  remainder  of  the  fluid  should  be  removed  in  one 
or  two  subsequent  aspirations.  Should  serum  continue  to  accumulate,  or  if  pus 
is  present,  after  a  proper  amount  has  been  withdrawn  there  should  be  injected, 
taking  great  care  to  exclude  any  possible  influx  of  air,  from  two  to  four  ounces 
of  a  two-per-cent  solution  of  formalin  in  glycerin.  This  should  be  repeated  every 
three  to  six  or  seven  days,  until  the  fluid  ceases  to  be  purulent,  and  every  two 
or  three  weeks  until  it  ceases  to  collect.  Prof.  J.  B.  Murphy  asserts  that  this 
treatment  will  cure  ordinary  hydrops  in  from  two  to  four  injections,  and  recom- 
mends it  highly  as  the  ideal  treatment  in  pleural  empyema.  To  avoid  the  danger 
of  collapse  of  the  lung,  drainage  should  never  be  instituted  in  these  simpler  cases 
until  it  is  absolutely  demonstrated  that  aspiration  with  the  injection  of  the  forma- 
lin-glycerin solution  has  failed. 

In  chronic  encapsulated  abscess,  where  the  danger  of  lung  collapse  does  not 
exist,  drainage  may  be  employed  and  frequently  exsection  of  a  considerable  portion 
of  one  or  more  ribs  is  necessary  in  order  to  effect  a  cure. 

Pneumonotomy. — Incision  of  lung  substance  may  be  required  in  evacuating 
a  pulmonary  abscess.  It  is  advisable  to  exsect  a  part  of  at  least  one  rib,  and  if 
adhesions  between  the  costal  and  pulmonic  pleurs  exist,  the  aspirating  needle 
should  be  used  to  indicate  the  depth  of  the  incision.  A  puncture  with  the  scalpel 
is  then  made,  and  through  this  a  closed  dressing  forceps  forced  until  the  cavity 
of  the  abscess  is  entered  and  the  opening  enlarged  by  separation  of  the  handles 
of  this  instrument. 

Irrigation  with  hot  saline  solution  should  be  made  and  free  drainage  estab- 
lished. When  no  adhesions  are  present,  and  if  delay  is  permissible,  an  effort  should 
be  made  to  secure  agglutination  of  the  opposing  jjleural  surfaces  by  depressing 
the  costal  pleura  by  means  of  a  gauze  pack  snugly  held  in  place  with  a  roller- 
bandage  around  the  chest.  In  five  or  six  days  adhesions  should  form  over  an 
area  large  enough  to  permit  incision  and  drainage  without  collapse  of  the  lung 
or  general  pleuritic  infection. 

In  pulmonary  gangrene  a  thorough  curettage  should  be  done  and  free  drain- 
age established.  Packing  the  cavity  with  sterile  gauze  may  be  necessary  to  pre- 
vent liEemorrhage. 

Pneumonectomy ,  or  the  removal  of  a  part  of  one  or  more  lobes  of  the  lung, 
is  occasionally  necessary  on  account  of  neoplasm,  hernia,  gangrene,  or  hemorrhage. 
Dr.  Lewis  Eassieur  reports  the  ligature  en  masse,  and  excision  of  about  one  and 
a  half  square  inches  of  the  lower  lobe  of  the  left  lung  on  account  of  haemorrhage 
from  a  pistol-shot  wound  which  also  penetrated  the  wall  of  the  heart.  The  hsemor- 
rhage  was  at  once  arrested  and  the  patient  recovered. 

Pneumorrhapliy,  or  suturing  the  lung  with  catgut,  has  been  successfully  per- 
formed in  a  number  of  instances  in  operations  for  the  removal  of  foreign  bodies, 
for  hernia,  gangrene,  cysts,  or  new  gro\\i;hs   (Ricketts). 

In  operating  for  wounds  of  the  pleura  and  lung  a  large  curved  incision  is 
advised,  the  wound  of  penetration  being  about  the  center  of  the  circle.  One  or 
two  ribs  should  at  first  be  divided  for  exploration,  and  a  larger  trap-door  made  as 
required.  These  operations  must  always  be  done  with  great  haste,  and  it  may  at 
times  be  necessary  to  instil  into  a  vein  normal  salt  solution  to  prevent  collapse 
while  the   chest  is  being  opened.     The  bleeding  king  should,   when  possible,  be 


THORAX  367 

brought  up  through  the  opening  in  the  chest  wall  and  ligated  en  masse  with 
chromicized  catgut. 

The  lung  is  occasionally  the  seat  of  malignant  neoplasms,  carcinoma  and  sar- 
coma. Cysts,  especially  those  caused  by  echinococcus,  when  recognized  shoidd  be 
subjected  to  operation. 

Bronchotomy. — Foreign  bodies  in  the  bronchus  may  be  recognized  by  the  X-ray 
as  well  as  by  auscultation  and  percussion.  When  removal  through  the  trachea  is 
impossible,  the  incision  through  the  chest  wall  should  be  at  the  nearest  possible 
approach  to  the  location  of  the  body.  Lodgment  is  more  frequently  in  the  right 
than  the  left  bronchus. 

SUEGEEY    OF    THE    HeAET 

CardiamorpMa,  or  malformations  of  the  heart,  are  scarcely  within  the  province 
of  surgery.^  Ectocardia,  or  malpositions,  may  be  congenital  or  acquired.  The 
heart  may  be  located  in  any  part  of  the  thoracic  cavity,  and  two  instances  are 
recorded  in  which  it  was  in  the  abdomen.  In  transposition  of  the  viscera  it  occu- 
pies the  right  side  of  the  chest.  Acquired  ectocardia  occurs  as  the  result  of  pleura) 
effusion,  aneurism  of  the  aorta,  or  pressure  displacement  from  a  mediastinal  tumor. 

With  aneurism  or  congenital  displacement,  operative  intervention  is  scarcely 
advisable.  In  effusion  into  the  pleura  the  evacuation  of  the  fluid  permits  the 
heart  to  resume  its  normal  position.  This  should  be  done  very  carefully  by 
aspiration,  since  fatal  results  have  followed  rapid  and  complete  evacuation  at  one 
operation.     (See  Pleura.) 

Cardioclasia,  or  rupture  of  the  heart  muscle,  has  occurred  in  rare  instances 
from  crushing  or  squeezing,  and  not  infrequently  from  intrinsic  weakness  result- 
ing from  fatty  degeneration. 

Wounds  of  the  heart  are  usually  caused  by  gunshot  missiles  or  knife  stabs. 
The  diagnosis  depends  chiefly  upon  the  location  and  direction  of  the  wound  of 
entrance  and  hfemorrhage  with  the  systole.  The  patient  is  usually  cyanotic  on 
account  of  interference  with  respiration  due  to  haemorrhage  into  the  pericardium, 
pleura,  or  lung.  There  is  an  expression  of  great  anxiety,  often  with  severe  pain. 
The  pulse  is  rapid  and  weak,  while  the  temperature  is  usually  subnormal.  The 
indications  in  treatment  are  rapid  exposure  of  the  heart  and  suture  of  the 
wound.  Stimulants  should  be  given  with  great  discretion,  since  increased  heart 
action  is  apt  to  increase  hjemorrhage.  Application  of  heat  to  the  body  is  advised. 
The  patient  should  not  be  moved  any  more  than  absolutely  necessary,  and  should 
then  be  carefully  lifted  by  hand. 

If,  upon  opening  the  cavity,  the  heart  has  ceased  to  beat,  it  should  be  gently 
and  rhythmically  massaged  between  the  thumb  and  finger,  and  artifieial  respira- 
tion practiced  with  any  indication  of  arrest  of  breathing.- 

Wounds  of  the  heart  may  be  penetrating,  or  may  divide  the  muscular  sub- 
stance without  entering  any  of  the  cavities.  Severe  hemorrhage  into  the  pericar- 
dial sac  may  cause  fatal  paralysis  of  the  heart  muscle  from  compression.  As  far 
as  the  prognosis  is  concerned,  recoveries  from  wounds  which  penetrate  and  those 

1  There  are  recorded  instances  in  which  the  heart  has  contained  two,  three,  five,  and  six 
separate  cavities.  The  author  acknowledges  his  indebtedness  to  the  "Surgery  of  the  Heart  and 
Lungs,"  by  B.  Merrill  Ricketts,  Ph.D.,  M.D.,  The  Grafton  Press,  New  York,  for  valuable  data 
derived  therefrom  and  used  in  this  chapter. 

2  Illustrative  Cases. — A  man  forty-seven  years  old,  who  had  received  a  knife  wound  of  the 
chest,  "suddenly  went  into  collapse  as  the  lung  was  exposed  during  an  operation.  Only  a  small 
quantity  of  ether  had  been  administered.  Notwithstanding  stimulation  and  artificial  respiration, 
the  patient  seemed  dead.  The  operator  grasped  the  heart  between  the  thumb  and  forefinger 
and  manipulated  it  from  forty  to  sixty  seconds,  when  it  began  to  contract.  Soon  after  a  second 
pulsation  occurred,  and  the  circulation  was  gradually  reestablished. — Dr.  W.  S.  Conkling,  "N.  Y. 
and  Phila.  Med.  Jour.,"  September  2,  1905. 

Direct  Massage  of  the  Heart  in  Chloroform  Collapse. — After  taking  chloroform  for  some  time 
the  patient  stopped  breathing  during  a  laparotomy  and  the  heart  ceased  to  beat.  _  Artificial 
respiration  was  done  while  the  operator  grasped  the  apex  of  the  heart,  through  the  diaphragm, 
by  taking  advantage  of  the  laparotomy  wound.  The  heart  was  stroked  regularly  with  the  thumb 
in  front  and  the  fingers  behind,  and  after  five  minutes  of  this  rhythmic  massage,  its  spontaneous 
contractions  were  resumed.  The  wound  was  sutured  immediately,  with  recovery. — Sensert, 
"Journal  de  Medicin  de  Paris,"  September  24,  1905. 


368  THORAX 

which  do  not  are  about  equal.  Eicketts  reports  fifty-six  cases  operated  upon,  with 
twenty  recoveries.  In  one  of  the  recoveries  the  coronary  artery  was  included  in 
the  suture. 

For  reaching  the  heart  in  an  emergency  (chloroform  narcosis  or  wound)  where 
massage  is  indicated,  a  long  incision  between  the  fourth  and  fifth  ribs  will  suffice. 
This  can  be  extended  if  necessary  by  rapid  division  of  the  costal  cartilages 
(Wilms).^  By  strong  retraction  up  and  down  a  fairly  good  view  of  even  the 
posterior  surface  of  the  organ  can  be  had  after  opening  the  pericardium.  In  one 
instance  a  bullet  wound,  involving  the  anterior  and  posterior  wall  of  the  left 
ventricle,  was  sutured  through  this  incision,  the  pericardium  being  closed  without 
drainage  with  recovery.  The  following  flap  method  is,  however,  the  best  for 
wounds  on  the  anterior  surface  of  the  heart : 

Stah  Wound  of  the  Heart.  IlliLstrative  Case. — Dr.  L.  L.  Hill,  Montgomery, 
Ala.,  operated  on  a  boy  thirteen  years  of  age  for  a  stab  woimd  received  at  five 
o'clock  Sunday  afternoon,  September  14,  1902.  The  knife  blade  entered  the  fifth 
intercostal  space  about  one  fourth  inch  to  the  right  of  the  left  nipple  and  pene- 
trating the  apex  of  the  heart  passed  into  the  left  ventricle.  There  was  no  external 
bleeding,  the  radial  pulse  was  almost  imperceptible,  and  the  heart  sounds  were 
heard  with  difBeulty.  There  was  dyspnoea  and  restlessness,  and  the  extremities 
were  cold.  Eight  hours  after  the  stabbing  an  incision  was  made,  beginning  five 
eighths  of  an  inch  from  the  left  border  of  the  sternum,  which  was  carried  along 
the  third  rib  for  four  inches.  A  similar  and  parallel  incision  was  made  along  the 
sixth  rib,  the  outer  terminals  of  the  two  being  joined  by  a  vertical  incision  along 
the  anterior  axillary  line.  The  third,  fourth,  and  fifth  ribs  were  cut  through  with 
the  pleura.  The  musculo-osseus  flap  was  raised,  the  cartilage  of  the  ribs  acting 
as  hinges.  There  was  no  bleeding  in  the  pleural  cavity,  but  the  pericardium  was 
enormously  distended.  The  opening  in  the  pericardium  was  enlarged  to  two  inches 
and  a  half,  and  about  ten  ounces  of  blood  evacuated.  The  pulse  immediately  im- 
proved. The  heart  was  lifted  from  the  pericardial  sac  by  the  hand  and  steadied, 
while  a  catgut  suture  was  passed  through  the  center  of  the  wound  in  the  wall  of 
the  left  ventricle,  which  was  three  eighths  of  an  inch  long.  This  controlled  the 
haemorrhage.  The  pericardial  sac  was  cleansed  with  normal  salt  solution,  emptied, 
and  the  opening  closed  with  seven  interruiDted  catgut  sutures.  The  pleural  cavity 
.was  also  cleansed  with  a  similar  solution  and  an  iodoform  gauze  drain  inserted. 
The  musculo-osseus  flap  was  stitched  in  position.  The  operation  lasted  forty-five 
minutes.  After  the  patient  was  put  to  bed,  strychnine  was  injected  hypodermically, 
and  hot  salt  solution  thrown  under  the  skin  and  in  the  colon.  The  patient 
recovered. 

Morris  -  reports  a  stab  wound  of  the  heai't  and  pleura  in  which  the  fourth 
costal  cartilage  was  resected,  the  wound  of  the  pleura  enlarged,  and  sterilized 
gauze  placed  in  the  cavity  of  the  pleura  to  steady  the  heart.  The  pericardial  wound 
was  also  enlarged,  exposing  a  stab  wound  three  quarters  of  an  inch  long  on  the 
antero-lateral  aspect  of  the  left  ventricle,  two  inches  above  the  apex.  Three  stitches 
of  fine  silk  were  passed  deeply  into  the  heart  muscle,  the  needle  being  inserted 
during  systole  while  the  knot  was  tied  during  diastole.  It  was  necessary  to  steady 
the  heart  in  the  hand  in  order  to  introduce  the  sutures.  The  pleura  was  next 
cleared  of  blood,  and  the  patient  recovered. 

Lenormant  ^  reports  128  cases  of  cardiac  suture  with  47  recoveries.  Of  these, 
in  58  the  wound  was  in  the  left  ventricle,  in  49  the  right,  while  5  were  in  the 
apex.  Of  those  wounded  through  the  left  ventricle,  25  recovered;  through  the 
right,  14.  There  were  3  cases  of  woiinds  of  the  right  auricle  with  2  recoveries, 
3  of  the  left  auricle  with  2  recoveries. 

As  far  as  the  post-operative  treatment  was  concerned,  in  23  cases  there  was 
no  drainage,  while  in  65  either  the  pericardium,  the  pleura,  or  both  were  drained. 
Of  the  65  drained  cases,  in  35  infectious  jfleuro-pericardial  complications  ensued, 
with  22  deaths.     Of  the  23  not  drained,  infection  occurred  in  only  5,  with  four 

>  "Centralblatt  fiir  Chir.,"  July  28,  1906. 

=  "Gazette  des  Hopitaux,"  September  13,  1906. 

3  "Year-Book  of  Surgery,"  J.  B.  Murphy. 


THORAX  369 

deaths.  From  this  it  seems  proper  to  conclude  that  drainage  should  he  avoidt'd 
in  all  cases  when  possible,  unless  infection  has  occurred. 

Eicketts  concludes  that:  "Whenever  the  location  of  a  wound  (with  attending 
symptoms)  justifies  the  suspicion  of  penetration  of  the  heart,  it  is  the  duty  of 
the  surgeon  to  determine  the  nature  of  the  injury  and  the  possibilities  of  relief 
by  an  exploratory  operation.  The  wound  should  never  be  probed.  The  heart 
should  be  steadied  before  attempting  to  suture  it.  Chromicized  catgut  inter- 
rupted sutures  should  be  used  and  should  not  include  the  endocardium." 

Adhesions  may  form  between  the  pericardium  and  the  pleura  or  chest  wall, 
and  interfere  with  heart  action  to  such  an  extent  as  to  require  operation.  The 
indications  are  the  exsection  of  the  rib  or  rilis  to  which  the  membrane  is  adherent, 
guarding  against  an  opening  into  the  pericardial  sac  (J.  B.  Murphy). 

Dropsy  of  the  Pericardium.. — The  removal  of  fluid  from  the  pericardium  is 
demanded  whene\'er  the  muscle  of  this  organ  is  interfered  with  by  compression. 
Careful  aspiration  with  a  tine  needle  through  the  fourth  or  fifth  intercostal  space 
should  be  done,  keeping  close  to  the  sternum. 

In  purulent  jDericarditis,  which  at  times  complicates  a  pneumonia,  paracentesis 
is  indicated   (Dr.  E.  G.  LeConte). 

Aneurism  may  occur  in  the  substance  of  the  heart  muscle  or  in  the  coronary 
artery.     This  condition  is  not  amenable  to  surgical  intervention. 

Foreign  hodies  are  extremely  rare  in  this  organ.  Hamilton  records  the  case 
of  a  Irallet  which,  being  lodged  in  the  neck,  worked  its  way  into  the  jugular,  and 
dropped  into  the  heart,  where,  becoming  encysted,  it  remained  over  twenty  years 
and  did  not  cause  death.  Cardioliths  may  exist  and  have  produced  obstructive 
symptoms  acting  as  emboli. 

Tumors. — In  addition  to  gumma  due  to  syphilis,  the  heart  may  he  the  loca- 
tion of  neoplasms,  fihroma  being  the  most  common.  Lipoma  and  angeipma  have 
been  reported.  Polypoid  growths  are  found  adherent  to  the  endocardium,  and 
occasionally  on  the  external  muscular  surface.  Sarcoma  and  cancer  are  also  re- 
ported, while  the  echinococciis  has  been  observed  and  has  proved  fatal.  In  extreme 
cases  exploratory  incision,  revealing  the  presence  of  an  echinococcus  cyst  or  any 
tumor  which  may  be  removed,  would  justify  a  radical  procedure. 


CHAPTEE   XIX 

THE    ABDOMEN 

CCELIOTOMT ABDOMINAL    INJURIES    IN    GENERAL WOUNDS    OP    THE    VISCERA 

In  abdominal  section  tlie  character  of  the  operation  to  be  performed  will  have 
much  to  do  with  determining  the  line  of  the  incision.  The  natural  route  would 
seem  to  be  through  the  median  line,  since  there  are  fewer  blood  vessels  to  be  en- 
countered here  and  practically  no  nerves  to  be  divided. 

Experience  has  shown,  however,  that  there  is  greater  danger  of  post-operative 
hernia  following  an  incision  exactly  in  the  median  line  than  when  this  incision 
is  made  slightly  to  one  or  the  other  side  of  the  linea  alba. 

This  is  especially  true  when  the  opening  is  made  below  the  umbilicus,  since 
from  this  point  to  the  symphysis  pubis  all  the  aponeuroses  of  the  oblique  and 
transverse  muscles  pass  in  front  of  the  rectus.  Above  the  umbilicus  the  aponeu- 
roses divide,  running  partly  in  front  and  partly  posterior  to  the  recti  muscles, 
and  in  suturing  the  peritonieum  from  the  navel  to  the  xiphoid  appendix  the  pos- 
terior sheath  of  the  rectus  and  peritoneum  are  included  in  the  same  suture. 

Post-operative  ventral  hernia  is  tlierefore  less  apt  to  occur  above  than  below 
the  navel.  Moreover,  the  suture  line  below  the  navel  is  subjected  to  more  strain 
on  account  of  the  greater  weight  of  the  abdominal  viscera  which  the  lower  halves 
of  these  muscles  are  called  upon  to  bear. 

For  these  various  reasons,  while  the  incision  above  the  navel  may  be  made 
in  the  linea  alba  that  below  the  level  of  the  umbilicus  should  be  made  about 
three  fourths  of  an  inch  from  the  inner  border  of  one  or  the  other  rectus  muscle, 
usually  the  right. 

Taking  this  for  purposes  of  demonstration,  the  sheath  is  incised  for  the  re- 
quired length,  exposing  the  muscle,  the  fibers  of  which  should  not  be  separated, 
but  the  inner  edge  of  the  rectus  through  the  entire  length  of  the  incision  lifted 
and  held  outward  by  retractors,  thus  exposing  the  peritonjeum  exactly  in  the  line 
of  the  anterior  incision.  In  this  way  no  nerves  are  divided  and  there  is  no  subse- 
quent paralysis  of  the  muscle,  whch,  after  the  peritonaeum  is  closed,  is  allowed 
to  fall  back  to  its  original  position. 

The  j)eritonseum  should  be  reunited  by  a  separate  running  suture  of  catgut. 
Ordinary  gut  will  suffice  in  the  majority  of  instances,  but  when  in  operations  above 
the  navel  the  posterior  sheath  of  the  rectus  must  be  included  in  the  peritoneal 
suture,  a  Ko.  3  ten-day  chromicized  catgut  is  preferable.  The  closure  of  the 
peritonaeum  is  greatly  facilitated  by  the  following  procedure: 

When  the  full  length  of  the  peritoneal  incision  is  reached,  retractors  of  linen 
or  silk  thread  of  good  size  should  be  introduced  from  within  out  through  the  ab- 
dominal peritonaeum  and  all  the  tissues  of  the  abdominal  wall.  One  of  these 
should  be  near  each  end  of  the  incision  and  one  about  half  an  inch  from  the 
edge  of  the  wound  on  either  side  and  near  its  middle. 

Should  there  be  distention  of  the  intestines  or  a  tendency  of  the  omentum  to 
protrude,  the  sutures  can  be  inserted  without  risk  of  wounding  these  organs  by 
using  a  sterile  spoon.  The  spoon,  convex  surface  downward,  serves  as  a  shield 
for  the  introduction  of  the  half-curved  Hagedorn  needle  (Monks),  and  the  ends 
are  tied  to  form  a  loop  about  ten  inches  in  length. 

These  looped  thread  retractors  are  of  great  value,  not  only  in  lifting  the 
abdominal  wall  and  exposing  the  viscera  to  view,  but  in  facilitating  the  intro- 
duction of  gauze  mats  and  the  rapid  and  safe  closure  of  the  peritoneal  incision. 

370 


THE  ABDOMEN 


371 


The  author  insists  upon  this  precaution  in  vievr  of  the  many  cases,  especially 
after  appendectomy,  in  which  he  has  been  called  upon  to  do  a  secondary  operation 
for  the  relief  of  imprisoned  omentum  or  mesentery  caught  in  the  peritoneal 
sutures  at  the  time  of  operation. 

After  the  peritonaeum  is  sutured,  the  chief  reliance  in  the  prevention  of  hernia 
is  in  overlapping  the  edges  of  the  aponeuroses  or  sheaths  of  the  recti  muscles 
and  of  holding  them  firmly  in  apposition  until  thorough  imion  is  secured.^ 

Prof.  John  Collins  Warren  has  called  attention  to  the  fact  that  in  connective- 
tissue  proliferation  under  aseptic  conditions,  the  time  required  for  the  organiza- 
tion or  fibrillation  of  the  new  connective  tissue  is  about  three  weeks.  This  he 
regards  as  a  "  surgical  unit  of  time '"  so  far  as  the  completed  healing  of  wounds 
under  the  most  favorable  conditions  is  concerned. 

It  should,  therefore,  be  imperative  to  keep  these  miiscles  as  much  at  rest  as 
possible  and  to  take  every  precaution  to  prevent  them  from  being  subjected  to 
pressure  or  strain,  for  at  least  this  length  of  time. 

In  limited  incisions  and  in  simple  operations,  such  as  may  be  done  through 
the  small  lIcBurney  incision  for  appendectomy,  a  patient  may  be  permitted  to 
be  up  and  about  at  an  earlier  date,  within  ten  days  or  two  weeks  from  the  opera- 
tion, but  in  extensive  incisions  the  conditions  are  entirely  different,  and  the  prac- 
tice of  permitting  these  patients  within  a  few  hours  or  two  or  three  days  to 
get  out  of  bed  and  move  about  is  not  advised. 

For  a  strip  one  half  inch  in  width  for  the  entire  length  of  the  incision,  the  fat 
is  dissected  from  the  anterior  surface  of  the  aponeurosis  or  sheath  on  the  left  side. 


Fig.  437. — Four  mattress  and  four  single  overlapping  sutures  for  approximating  the  aponeuroses. 
(After  Chanipionniere  and  Xoble.) 


The  sheath  upon  the  right  side  of  the  wound  is  lifted  from  the  rectus  muscle  for 
an  equal  width  and  distance.  This  is  the  overlapping  layer.  The  fascije  are  now 
overlapped  and  securely  held  by  strong  kangaroo-tendon,  mattress,  or  U-shaped 
sutures,  as  employed  by  Championniere  in  his  operation  for  inguinal  hernia 
(Fig.  4.37). 

'  Within  recent  years,  partly  upon  the  initiative  of  Lueas-Championniere.  and  later,  E. 
Wyllys  Andrews,  of  Chicago,  who  applied  the  overlapping  method  for  closure  of  the  external 
abdominal  ring  in  herniotomy,  but  more  particularly  to  Dr.  Charles  P.  Noble,  of  Philadelphia, 
who  first  demonstrated  the  practical  results  of  overlapping  the  aponeuroses  as  appUed  to  the 
abdominal  wall  in  general,  this  great  advance  in  abdominal  surgery  has  been  made. 


372 


THE  ABDOMEN 


The  needle,  as  shown  in  Fig.  437,  is  first  introduced  from  without,  in  through 
the  right  aponeurosis,  one  half  inch  from  the  cut  edge,  and  up  through  the 
opposite  aponeurosis  an  eighth  of  an  inch  from  the  edge,  back  again  in  a  loop 
suture  a  fourth  of  an  inch  wide,  to  come  out  finally  in  line  with  and  one  fourth 
of  an  inch  from  the  original  point  of  entrance.  These  sutures  should  be  half  an 
inch  apart.  An  intermediate  kangaroo-tendon  suture  is  inserted  as  shown  in 
the  drawing.  Fig.  438  illustrates  the  overlapping  secured  by  tying  the  U-shaped 
or  mattress  suture.     The  reenforcing  or  tension  suture  is  not  jet  tied. 

This  method  of  overlapping  the  aponeurosis  may  be  varied  to  suit  different 
conditions.  When  the  abdomen  is  flaccid  the  overlapping  surface  need  not  be 
more  than  one  fourth  of  an  incli,  and  a  simpler  running  suture  of  kangaroo  tendon 


'■^■\,  ,.:.--_ 

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1. 

Fig.  43S. — The  same.     The  four  single  sutures  not  yet  tied. 


the  method  of  insertion  of  which  is  shoA^oi  in  Fig.  439,  will  suflice,  or  the  modified 
mattress  suture,  as  shown  in  Fig.  440,  may  be  substituted. 

Sutures  directly  in  the  muscle  substance  are  of  doubtful  proprietj'^,  for  the 
reason  that  the  fasciculi  are  apt  to  cut  through  from  too  great  tension  in  their 
insertion,  or  as  a  result  of  muscular  contraction  after  the  operation.  If  used  at 
all  they  should  be  interrupted  and  only  loosely  tied. 

Wliere  there  is  considerable  fat  in  any  abdominal  incision  it  should  be  brought 
together  liy  a  sul^cutaneous  suture,  as  shown  in  Fig.  74,  while  the  skin  itself  ma)^ 
be  tmited  Ijy  the  endocuticular  suture. 

Incisions  through  the  linea  semilunaris  are  objectionable  for  the  reason  that 
not  only  are  the  same  nerves  divided  that  would  be  cut  in  splitting  the  rectus, 
but  there  is  also  not  enough  muscular  and  aponeurotic  tissue  here  to  give  a  firm 
and  resistant  imion.  Wlien  this  part  of  the  abdominal  wall  is  in  tlie  field  of 
operation,  it  would  be  better  to  lean  to  one  side  or  the  other  of  this  line,  splitting 
the  sheath  of  the  rectus  and  temporarily  displacing  this  muscle  by  preference, 
or  the  McBurney  method  of  separating  the  fibers  of  the  aponeurosis  of  the  external 
oblique  and  the  muscle  fibers  of  the  internal  oblique  and  transversalis.  For 
draining  an  appendicular  abscess  or  removing  the  appendix  in  the  uncomplicated 
cases  of  interval  operations,  this  incision  is  ideal.     The  muscle-splitting  incision 


THE   ABDOMEN 


373 


of  Deaver  is,  however,  preferable  in  the  vast  majority  of  cases,  for  the  reason 
that  no  matter  what  comjDlications  are  encountered  it  can  be  enlarged  to  any 
extent  without  the  danger  of  hernia.  Other  special  incisions  of  the  abdominal 
wall  will  be  considered  with  the  operations  of  wliich  they  are  a  part. 


M 

//^^ 

i   J  t 

"  «i^ 

^M 

f 

^ 

^. 

Fig.  439. — Showing  method  of  introducing  the 
continuous  or  running  suture  for  overlapping 
the  aponeuroses.     (Noble.) 


Fig.  440. — Showing  method  of  introducing  four 
mattress  tendon  sutures  for  overlapping  the 
aponeuroses.      (Noble.) 


Abdominal  Injuries  in  General. — Extensive  injuries  may  be  inflicted  upon  the 
abdominal  viscera  without  outward  signs,  and  at  times  with  no  immediate  symp- 
toms proportionate  to  the  gravity  of  the  internal  lesion.  The  bowel  has  been 
completely  severed  by  a  wagon  wheel,  the  patient  walking  immediately  after  the 
injury  a  considerable  distance  without  shock  or  pain.'  In  the  majority  of  in- 
stances, notwithstanding  the  abdominal  wall  is  stronger  below  the  navel  than 
above  it,  the  injuries  are  found  in  the  lower  abdomen.  Seemingly  slight  acci- 
dents cause  serious  and  fatal  injury.  Senn  reports  a  case  of  rupture  of  the  intes- 
tine due  to  the  patient's  slipping  to  the  groimd,  striking  on  the  buttock.  In  the 
same  way  the  liver  and  spleen  may  be  ruptured.  Two  cases  of  intestinal  rup- 
ture have  occurred  from  a  blow  on  the  back  near  the  spinal  column.  In  thirty- 
six  cases  of  horse  kick  upon  the  abdomen,  intestinal  rupture  occurred  in  thirty-five. 
In  determining  the  gravity  and  location  of  the  injury,  although  the  site  of  impact 
does  not  always  guide  one  to  the  lesion,  this  should  be  considered.  If  a  blow  has 
been  received  over  the  right  hypochondrium,  followed  by  a  weak  jJulse  and  other 
signs  of  anasmia,  with  shock,  hepatic  rupture  should  be  suspected.  The  same 
would  be  true  in  regard  to  a  blow  received  over  the  spleen,  which  is  the  most 
readily  ruptured  of  all  the  abdominal  viscera. 

The  careful  consideration  of  the  general  condition  of  the  patient  at  the  time 
of  accident  is  of  importance.  An  enlarged  spleen  or  liver,  distended  stomach  or 
bladder,  or  presence  of  a  large  hernia,  as  well  as  the  expectedness  of  the  blow,  are 
all  important  factors.  If  injury  is  even  momentarily  expected,  muscular  tension 
will  do  much  to  prevent  rupture. 

Treves  suggests  that  the  thickness  of  the  fat  over  the  part  struck  is  to  be 
considered  in  arriving  at  a  diagnosis,  as  well  as  the  position  of  the  patient  at  the 
time  of  accident. 

In  the  majority  of  instances  initial  shock  is  present,  although  its  severity  and 


374  THE  ABDOMEN 

duration  are  not  reliable  criteria  as  to  the  extent  of  intra-abdominal  injury. 
Severe  and  persistent  shock  is  suggestive  of  heemorrhage,  and  when  this  is  accom- 
panied by  a  rapid,  weak  pulse,  restlessness,  sense  of  suffocation,  thirst,  cold 
perspiration,  a  diagnosis  of  haemorrhage  is  practically  sure.  In  most  cases  pain 
is  present.  According  to  Dr.  Kobert  Le  Conte,  one  of  the  most  valuable  signs  is 
muscular  rigidity.  He  states  that  the  characteristic  of  visceral  injury  is  pro- 
gressive rigidity,  usually  of  boardlike  hardness. 

Persistent  vomiting  is  of  great  diagnostic  value.  If  bloody,  the  stomach  and 
upper  intestinal  tract  are  naturally  under  suspicion. 

Increasing  pidse-rate  is  ominous.  Fowler  claims  that  a  gain  of  from  ten  to 
fifteen  beats  an  hour  is  significant  of  intra-abdominal  rupture. 

Facial  expression  should  always  be  carefully  considered. 

Brewer  asserts  that  deep-seated,  localized  pain  following  an  abdominal  injury, 
especially  if  increased  by  pressure  and  accompanied  by  local  and  general  rigidity, 
is  one  of  the  most  common  symptoms  of  visceral  injury. 

Lesions  of  the  small  intestine  are  more  serious  than  the  large,  by  reason  of 
the  mobility  of  this  part  of  the  alimentary  canal  and  the  greater  danger  of  the 
general  dissemination  of  intestinal  contents. 

The  prognosis  depends  upon  the  time  which  elapses  between  the  injury  and 
the  operation,  as  well  as  the  character  of  the  treatment.  In  all  cases  of  doubt 
exploration  should  be  advised.  If  the  symptoms  of  acute  hasmorrhage  are  present, 
and  there  is  shock,  the  additional  risk  of  operation  may  be  incurred,  since  death 
is  inevitable  from  bleeding.  Ligation  of  the  extremities,  and  the  sequestration 
of  as  much  blood  as  is  possible  in  the  legs  and  arms,  should  be  part  of  the  emer- 
gency treatment  in  all  cases  of  profuse  internal  hagmorrhage.  The  head  should 
be  lowered  in  order  to  maintain  the  cerebral  circulation.^ 

Wounds  of  the  abdomen  are  divided  into  penetrating  and  non-penetrating ,  and 
both  of  these  varieties  are  again  divisible  into  those  which  involve  the  viscera  and 
those  in  which  the  organs  escape. 

Contusions  may  involve  the  integument,  produce  extravasation  in  the  sub- 
cutaneous tissues,  rupture  of  the  muscles,  or  displacement  or  rupture  of  a  viscus 
and  death  without  any  external  evidence  of  injury. 

Simple  contused  wounds  of  this  region  demand  no  especial  consideration.  If 
abscess  or  ha3matoma  occurs,  the  same  rule  of  treatment  which  applies  elsewhere 
is  applicable  here.  Rupture  of  one  or  more  of  the  muscles  may  occur  as  the  result 
of  a  blow  on  a  muscle  in  tension,  or  by  muscular  action  alone.  The  rectus  abdomi- 
nalis  is  most  frequently  torn.  Hernia  is  apt  to  follow  this  injury  unless  imme- 
diate union  is  secured  by  freshening  the  ruptured  surfaces  and  uniting  them  by 
suture.  The  overlapping  technic  (Noble)  applied  to  muscular  tissue  and  the 
aponeuroses  is  essential.  Perfect  rest  and  well-adjusted  support  are  also  of  great 
importance  in  insuring  success. 

Displacement  or  rupture  of  an  organ  (as  the  kidney,  spleen,  etc.)  may  be 
caused  by  direct  violence  or  by  a  severe  fall.  The  diagnosis  will,  in  the  first  lesion, 
depend  upon  the  absence  of  the  organ  from  its  normal  place  and  the  recognition 
of  the  tumor  in  the  new  position.  Laceration  is  followed  by  liEemorrhage,  at  times 
profuse,  which  is  evident  from  great  pallor  and  a  rapid  and  weak  pulse.  If  the 
intestine  is  involved,  the  escape  of  gas  or  fajces  is  followed  usually  by  profound 
shock,  tympanites,  and  peritonitis.  Emphysematous  crackling  may  be  recognized 
on  palpation. 

The  first  indication  in  treatment  of  a  displaced  viscus  is  to  place  the  patient 
in  such  a  posture  that  gravity  will  aid  in  the  restoration  of  the  organ  to  its  normal 
position.  A  compress  and  bandage  may  be  useful  in  some  instances.  In  rupture 
of  a  solid  organ  profound  quiet  should  be  maintained.  When  hfemorrhage  is 
alarming,  deligation  of  the  extremities  is  advisable.  If  the  symptoms  of  rupture 
of  the  alimentary  canal  are  present,  the  abdomen  should  be  opened  in  the  median 
line,  the  rupture  closed,  or  an  artificial  anus  established,  and  the  peritoneal  cavity 
carefully  cleansed.    -  , 

'  The  author  acknowledges  his  indebtedness  to  the  excellent  contribution  of  Dr.  H.  C.  Daltoij 
jn  the  "Journal  of  the  Missouri  State  Medical  Association,"  vol.  iii,  Nov.  8,  1907, 


THE  ABDOMEN  375 

Non-penetrating  incised,  punctured,  or  sliot  wounds  of  this  region  do  not  de- 
mand esjjecial  consideration.  The  former  should  be  closed,  while  it  is  usually- 
safer  to  treat  the  punctured  and  shot  wounds  by  placing  a  sublimate  compress 
over  the  opening. 

Penetrating  Wounds. — Wounds  of  the  abdomen  which  penetrate  without 
wounding  any  internal  organ  should  be  closed  in  the  same  manner  as  directed 
for  the  closure  of  surgical  wounds  through  the  belly.  If  an  internal  organ  is 
involved  the  abdomen  should  be  opened,  the  character  of  the  lesion  ascertained, 
and  proper  surgical  treatment  instituted,  Among  the  symptoms  which  aid  in 
arriving  at  a  diagnosis  are  the  following:  If  the  injury  is  followed  by  the  vomit- 
ing of  blood  it  is  fair  to  conclude  that  the  stomach  or  duodenum  is  involved; 
if  blood  is  passed  by  the  rectum,  that  the  wound  is  farther  along  the  bowel;  or, 
if  hematuria  exists,  that  the  kidney,  ureter,  or  bladder  is  injured.  If  the  odor 
of  intestinal  gas  or  faeces  is  present,  the  inference  is  clear  that  the  alimentary 
canal  is  opened.  Bile,  gastric  juice,  or  recently  ingested  matter  seen  in  the  wound 
or  recognized  by  the  sense  of  smell  indicates  the  character  of  the  injury  and  the 
location  of  the  perforation.  The  crackling  sound  peculiar  to  emphysema,  elicited 
by  palpation,  indicates  the  presence  of  intestinal  gas  in  the  loose  tissues,  beneath 
the  peritonaeum  (Dennis).  Tympanitic  resonance  over  the  liver,  which  has  ap- 
peared suddenly  and  which  is  persistent,  is  a  diagnostic  sign  of  perforation  of 
considerable  value.  Shock  is  usually  severe,  although  in  some  cases  it  may  be 
slight  and  of  short  duration. 

In  shot  wounds  the  location  of  the  wound  of  entrance  (and  exit,  if  it  exists), 
together  with  the  known  direction  of  the  missile  and  the  force  with  which  it  was 
propelled,  will  be  of  aid  in  determining  the  character  of  the  lesion  within.  A 
bullet  passing  directly  or  obliquely  into  the  abdomen,  at  or  below  the  level  of  the 
umbiiiciis,  can  scarcely  miss  the  intestinal  tube,  and  will  be  more  apt  to  make  a 
number  of  holes  than  a  single  wound.  Above  this  point  the  chances  of  escape  are 
more  favoraljle,  yet  so  fortunate  a  result  is  exceptional.  The  direction  and  depth 
of  a  stab  wound  may  also  be  determined  by  the  appearance  of  the  wound  and  an 
examination  of  the  instrument  with  which  it  was  inflicted.  The  persistence  of 
pain  in  a  given  point  within  the  abdomen  is  a  recognized  symptom  of  a  pene- 
trating wound. 

Many  of  the  foregoing  symptoms  may  not  be  present  within  the  first  few 
hours  after  the  receipt  of  a  wound  which  has  penetrated  the  alimentary  canal, 
and  beyond  the  external  wound  and  a  varying  degree  of  shock  there  may  be 
no  symptom  of  perforation.  Temporary  contraction  of  the  muscular  fibers  of 
the  stomach  or  intestine,  or  prolapse  of  the  mucous  meml)rane  into  the  wound, 
may  prevent,  for  a  time,  the  escape  of  gas  or  ingested  matter,  and  the  appear- 
ance of  the  more  pronounced  symptoms  of  perforating  wounds  of  the  alimen- 
tary  canal. 

Treatment. — When  there  is  a  wound  in  the  wall  of  the  abdomen,  the  immediate 
indication  is  to  determine  whether  it  opens  into  the  cavity.  In  order  to  do  this, 
the  disinfected  finger,  or  preferably  the  light  and  porcelain-tipped  Nelaton  probe, 
should  be  introduced,  and,  if  necessary,  the  opening  enlarged.  Cocaine  anajsthesia 
may  be  sufficient  for  this  procedure.  The  peritonamm  lining  the  abdominal  wall 
will  require  careful  infiltration.  If  the  wound  is  confined  to  the  abdominal  wall 
it  should  be  treated  in  the  aseptic  method  advised  for  ordinary  wounds  of  the 
soft  tissues.  If  it  extends  through  the  wall,  the  abdomen  should  be  opened 
and  the  condition  of  the  viscera  examined.  As  to  whether  the  incision  should 
be  an  enlargement  of  the  accidental  wound  or  made  in  the  median  line,  the 
location  and  direction  of  the  wound  must  determine.  The  section  should  be, 
preferably,  near  the  linea  alba.  (See  Cceliotomy.)  If  the  lesion  is  not  more 
than  six  inches  from  this  line,  and  if  the  direction  of  the  wound  is  backward 
or  tending  toward  the  center,  this  incision  should  be  chosen.  Under  other  con- 
ditions the  "section  may  be  through  the  wound  of  entrance  or  elsewhere.  _  (See 
Cceliotomy. ) 

In  this  procedure  the  details  of  the  antiseptic  method  should  be  carried  out, 
as  directed  in  operation  for  the  relief  of  intestinal  obstruction.     When  the  peri- 


376 


THE  ABDOMEN 


toneal  cavity  is  opened,  if  it  contain  clotted  blood  which  is  known  not  to  have 
entered  from  the  wound  of  oiDcration,  or  ingested  matter,  or  if  gas  escape  through 
the  opening,  the  penetrating  character  of  the  wound  is  evident.  If  none  of  these 
signs  are  present  the  disinfected  hand  should  be  introduced  and  the  internal  sur- 
face of  the  wall  examined  at  the  supposed  point  of  entrance.  In  examining  the 
intestinal  canal  it  is  usually  advisable  to  begin  with  the  loop  which  presents  at  the 
incision. 

This  should  be  marked  for  identification  by  a  loop  suture  passed  tlrrough 
the  mesentery  and  around  the  gut,  leaving  the  ends  tied  long.  In  the  search  for 
perforations  it  is  best  to  pass  the  bowel  from  the  starting  point  in  one  direction 
on  and  on  through  the  fingers  without  drawing  the  loops  outside  the  abdominal 
cavity.  This  procedure  may  be  greatly  facilitated  by  inserting  the  loop  suture 
retractors,  which  it  is  advisable  to  introduce  through  the  abdominal  wall  on 
either  side  of  the  center,  and  at  each  end  of  the  incision.  Traction  on  these 
loops,  at  the  same  time  lifting  the  abdominal  wall  forward,  gives  much  more 
room  for  inspection  and  maniprUation  within  the  abdomen.  When  a  perforation 
is  encountered  it  should  be  temporarily  closed  with  a  small  clamp  shielded  with 
rubber,  which  should  not  compress  the  bowel  hard  enough  to  produce  necrosis.  If 
necessary  the  loop,  in  the  center  of  which  is  the  perforation,  may  be  drawn  out 
of  the  abdominal  incision  and  immediately  covered  by  gauze  or  towels  taken 
from  hot  salt  solution.  Any  extravasated  matter  from  this  particular  jjerforation 
should  be  carefully  mopped  up  with  gauze,  wet  in  1-2000  mercuric-chloride  solu- 
tion and  squeezed  so  that  the  mercury  may  not  be  left  in  the  peritoneal  cavity. 
In  using  swabs  or  sponges  in  a  toilet  of  the  jjeritonaaum  rough  swabbing  should 
not  be  done,  since  hypersemia  and  an  inflammatory  exudate  with  adhesions  is 
very  readily  induced  in  this  membrane.  The  search  should  now  be  continued 
until  all  of  the  intestinal  tract  above  the  starting  point  has  been  examined, 
or  as  far  as  the  character  of  the  injury  will  indicate  as  necessary.  The 
same  method  of  search  should  be  employed  on  the  other  side  of  the  starting 
point. 

In  closing  intestinal  perforations  or  penetrating  wounds,  the  following  method 
should  be  employed :  For  a  small  incision  or  stab  wound  the  Lembert  suture,  shown 
in  Fig.  443,  is  ideal.  The  needle  is  introduced  into 
the  peritoneal  covering  of  the  bowel  wall  one  eighth 
of  an  inch  from  the  cut  edge,  and  is  made  to  pass 
just  deep  enough  to  include  the  muscular  layer  down 
to  the  mucous,  and  is  brought  out  through  the  serovis 
surface  right  at  the  edge  of  the  incision.  It  is  car- 
ried across  to  the  opposite  side  and  inserted  reversely 
in  the  same  manner.  It  includes  a  bite  one  eighth 
of  an  inch  wide,  and  when  tied  brings  in  close  appo- 
sition this  much  of  peritoneal  surface,  which  quickly 
unites  to  prevent  leakage.  The  peritoneal  surfaces 
thus  approximated  and  held  in  contact  will,  by  the 
exudation  of  plastic  lymph  and  cell  proliferation, 
form  adhesions  within  six  hours  of  the  introduction 
of  the  sutures.  These  stitches  should  under  no  cir- 
cumstances be  more  than  one  eighth  of  an  incli  apart 
throughout  the  length  of  the  wound  to  be  closed, 
closing  wounds  of  theintestines.  ^''^^  ^f  f^s  ends  it  is  a  wise  precaution  to  insert  an 
(After  Esmarch.)  additional  suture  more  than  might  possibly  be  re- 

quired, as  the  angles  are  the  weak  points  in  intestinal 
suture.  If  the  loss  of  substance  is  extensive,  necessitating  a  wide  excision,  and  there 
should  be  danger  of  tension  upon  the  sutures,  it  would  be  a  wise  precaution  to  in- 
troduce one  row  of  the  Mayo-mattress  ten-day  catgut  one  sixteenth  inch  from  the 
edge,  and  reenforce  this  by  the  Lembert  or  the  Gushing  linen  suture.  A  small  stab 
or  incised  wound  of  a  hollow  viscus  may  practically  always  be  closed  without  re- 
gard to  the  direction  of  the  opening  through  the  wall,  and  when  there  is  no  loss 
of  substance  the  Lerabert  suture  above  described  sacrifices  such  a  small  strip  of 


Leinbert's    suture 


THE  ABDOMEN  377 

bowel  that  the  caliber  of  the  gut  is  not  materially  lessened.  In  gunshot  wounds 
which  are  more  or  less  lacerated,  and  which  may  at'  times  pass  thi-ough  the  bowel 
in  such  a  way  as  to  necessitate  the  excision  of  a  considerable  portion  of  the  bowel 
wall,  the  question  may  arise  whether  an  immediate  resuture  slioidd  be  made  or 
whether  an  excision  is  preferable.  If  the  hole  has  been  made  by  a  bullet  and 
has  rough  or  torn  borders,  the  edges  should  be  trimmed  smooth  with  curved  scis- 
sors and  then  closed.  Should  a  very  narrow  strip  of  tissue  separate  two  openings, 
it  is  generally  safer  to  convert  them  into  a  single  elliptical  wound.  In  uniting 
a  considerable  wound  of  the  wall  of  the  intestine,  the  line  of  sutures  should,  when 
possible,  be  transverse  to  the  axis  of  the  bowel,  for  while  the  sutures  in  this 
direction  may  slightly  kink  or  angulate  the  bowel,  they  do  not  impinge  upon  the 
lumen  of  the  gut  so  much  as  those  in  which  the  line  of  suture  is  parallel  witia  the 
long  axis.  Bather  than  diminish  the  lumen  of  the  bowel  beyond  one  third  of 
its  normal  capacity,  it  would  be  better  to  excise  and  reunite  by  suture  or  by 
use  of  the  Murphy  button  should  the  patients  condition  be  such  as  to  contra- 
indicate  the  longer  operation.  If  a  Murphy  button  is  not  at  hand  and  the  con- 
dition of  the  patient  is  bad,  Bodine's  temporary  artificial  anus  method  should 
be  substituted. 

"W^hen  the  small  intestine  only  is  involved,  in  the  hands  of  one  expert  with 
the  needle,  end-to-end  anastomosis  is  advised,  provided  always  that  the  condition 
of  the  patient  will  justify  any  operation.  In  anastomosis  between  large  and  small 
intestine  lateral  union  is  preferal3le.  In  an  emergency  the  Murphy  button  (round 
or  olilong)   is  of  great  value. 

When  visceral  extravasation  has  occurred  the  method  of  cleansing  tlie  peri- 
toneal cavity  should  be  determined  Ijy  the  extent  and  location  of  the  extravasation. 
If  there  is  only  a  perforation  at  one  point,  with  a  very  limited  leakage,  which 
is  not  infrequently  the  case  where  a  small  caliber  bullet  has  passed,  it  would 
be  better  to  make  a  careful  local  toilet,  mopping  the  extravasated  matter  away 
carefully  with  swabs  taken  from  1-2000  hot  mercuric-chloride  solution,  the  excess 
being  squeezed  out  before  using.  This  mopping  should  be  followed  with  a  second 
cleansing  with  hot  salt  solution  in  order  to  remove  or  neutralize  any  excess  of  mer- 
cury. Unless  a  general  widespread  peritonitis  has  already  been  established,  irri- 
gation is  not  advisable,  for  fear  of  spreading  a  localized  infection  to  portions  of 
the  peritoneal  cavity  not  yet  involved.  In  all  of  these  traumatic  infectious 
processes  below  the  navel  the  Fowler  posture  is  very  essential.  Above  this  level 
an  effort  should  be  made  by  the  recumbent  posture  to  confine  the  infection  to  a 
limited  area.  If  there  has  been  a  gravitation  of  extravasated  matter  into  the 
pelvis,  a  free  near-median  line  incision  should  be  made  in  order  to  permit  of  the 
most  thorough  inspection  and  cleansing  of  the  peritonajimi. 

In  a  toilet  below  the  umlailicus  a  certain  amount  of  hot  salt  solution  may  be 
safely  employed,  provided  that  the  Fowler  position  is  carefully  maintained  and 
that  "pelvic  drainage  is  established  when  indicated.  Drainage  of  the  pelvis  is  best 
secured  in  females  by  opening  through  Douglas'  cul-de-sac,  inserting  here  a  Van 
Buren  Knott  rubber  and  gauze  drain"  and  in  males  the  double  supravesical  drain- 
age.    (See  Diffuse  Suppurative  Peritonitis.) 

No  especial  treatment  can  be  laid  do-rni  for  wounds  of  the  solid  viscera  or 
of  the  great  vessels.  The  arrest  of  haemorrhage,  the  removal  of  extravasated  blood, 
and  the  establishment  of  drainage  when  needed  are  the  indications. 

The  argument  in  favor  of  operative  interference  in  penetrating  or  supposed 
penetrating  wounds  of  the  abdomen  may  be  briefly  stated  as  follows: 

1.  The  enlargement  of  a  wound  sufficiently  to  demonstrate  whether  or  not  it 
opens  into  the  cavity  of  the  peritoneum  is  a  simple  procedure,  practically  without 
danger.     Cocaine  anaesthesia  should  suffice. 

2.  Abdominal  section  is  not  a  difficult,  nor,  under  ordinary  conditions,  when 
properly  performed,  a  dangerous  operation. 

3.  A  penetrating  wound  of  the  abdomen,  left  ^vithout  siirgical  interference,  is 
always  attended  with  extreme  danger. 

4.  If  any  vessels  of  size  are  divided,  haemorrhage  is  an  inimediate  danger,  and 
peritonitis  a  serious  and  probably  fatal  complication. 


378  THE  ABDOMEN 

6.  If  the  alimentary  canal  is  opened,  death  is  almost  inevitable.  The  few- 
recorded  cases  of  recovery  form  such  an  infinitesimal  proportion  of  the  whole  that 
they  should  carry  no  weight  against  interference.^ 

1  It  may  be  justly  claimed  that  to  American  surgery  is  due  the  great  advances  which  have 
been  made  in  the  treatment  of  penetrating  wounds  of  the  abdominal  cavity.  In  1847  Dr.  Newell, 
of  New  Brunswick,  N.  J.,  "made  an  abdominal  incision  and  sutured  the  intestine  in  a  case  of  gun- 
shot wound,  cleansed  the  cavity,  closed  the  wound,  and  the  patient  recovered." 

A  similar  operation  was  done  by  Kinloch,  of  South  Carolina,  in  1SS2,  and  by  KoUock,  of  the 
same  State,  in  1884,  who  sutured  two  pistol-shot  wounds  of  the  colon  and  one  of  the  small  intestine, 
with  a  successful  result. 

The  operation  was  not  brought  prominently  before  the  profession  until  the  celebrated  paper 
of  Dr.  J.  Marion  Sims  was  read  before  the  New  York  Academy  of  Medicine,  on  October  6,1881. 
This  paper  attracted  widespread  attention,  and  may  truly  be  said  to  be  the  starting  point  in  the 
surgical  invasion  of  the  abdominal  cavity  for  penetrating  wounds. 

In  1884  Dr,  Bacon  Saunders,  then  of  Bonham,  Texas,  opened  the  peritoneal  cavity  after  a 
stab  wound  with  symptoms  of  haemorrhage,  tied  the  mesenteric  artery,  which  had  been  divided, 
and  cleansed  the  cavity,  with  a  successful  result.  A  brilliant  case  of  (intraperitoneal)  gunshot  ■ 
wound  of  the  bladder,  the  first  on  record,  was  reported  by  Dr.  Amos  B.  Walker,  of  Texas,  and  is 
given  in  the  chapter  on  injuries  of  the  bladder.  In  1885  Dr.  W.  T.  Bull  successfully  performed 
his  operation  for  multiple  perforation  by  a  pistol  ball.  In  1886  Dr.  W.  O.  Roberts,  of  the  Univer- 
sity of  Louisville,  operated  for  a  stab  wound  of  the  intestine,  with  success.  Following  this  pioneer 
work,  successful  cases  have  been  reported  of  late  years  in  many  instances. 


CHAPTER   XX 

THE  STOMACH 

PENETRATING    WOUNDS FOREIGN    BODIES CICATRICIAL    CONTRACTIONS TUMORS — 

GASTROTOMY ULCERS PARTIAL    OR    COMPLETE    GASTRECTOMY GASTRO-ENTER- 

OSTOMY  GASTKO-PY'LORECTOMY  DUODENO-GASTROPLASTY  GASTROPTOSIS 

■ — GASTROPLICATION CARCINOMA SARCOMA DUODENAL      ULCER PERFORA- 
TION 

Among  tlie  surgical  lesions  of  the  stomach  are  the  lodgment  of  foreign  bodies, 
penetrating  ivounds,  ohstruciions  due  to  congenital  malformation  or  cicatricial 
contractions  (hour-glass  stomach,  pyloric  stenosis)   adhesions  and  tumors. 

Certain  conditions  of  dilatation  and  displacement  due  to  hyperdistention  or 
atony  are  also  at  times  properly  considered  amenable  to  surgical  intervention, 
while  gastric  ulcer,  the  most  important  of  all  the  pathological  conditions  of  this 
organ  in  recent  years,  has  been  accorded  an  unusually  prominent  place  in  the 
list  of  surgical  ■  diseases. 

Foreign  Bodies. — The  presence  of  foreign  bodies  in  the  stomach  may  be  recog- 
nized by  the  X-ray  when  the  substance  is  metallic;  by  palpation,  as  in  the  case  of 
gastroliths  of  considerable  size  fonned  by  the  accretion  of  ingested  matter;  by  the 
endoscope  or  gastroscope;  and  lastly,  when  other  means  fail,  by  surgical  exjjlora- 
tion.     For  their  removal  the  operation  of  gastrotomy  is  necessary. 

In  this  operation  the  organ  is  exposed  by  the  incision  which  splits  the  left 
rectus  half-way  between  the  xiphoid  appendix  and  navel,  usually  enlarged  in 
whatever  direction  may  be  required  after  the  situation,  size,  and  shape  of  the 
body  to  be  removed  has  been  ascertained.  When  the  stomach  is  fully  exposed, 
an  effort  should  be  made  to  draw  it  up  into  and  through  the  wound  as  far  as 
possible,  where  it  is  held  by  silk  threads  inserted  into  the  walls,  the  needle  which 
introduces  these  not  passing  into  the  lumen.  The  organ  may  then  be  incised, 
and  the  foreign  body  extracted  either  by  the  linger  or  a  suitable  instrument. 
Great  care  should  be  taken  to  so  protect  the  margins  of  the  abdominal  incision 
with  mops  of  gauze  as  to  prevent  the  entrance  of  any  septic  matter  into  the 
peritoneal  cavity.  The  wound  in  the  stomach  should  be  closed  by  the  Mayo-Cush- 
ing  double  mattress  suture  method.  If  the  stomach  cannot  be  drawn  up  into 
the  wound,  the  abdominal  incision  may,  if  necessary,  be  further  enlarged  and 
sterilized  pads  inserted  in  such  a  way  that  the  contents  of  the  stomach  cannot 
cozne  iu  contact  with  the  peritonaeum  after  it  has  been  incised.  The  same  method 
of  suture  for  the  stomach  wall  should  be  employed. 

It  is  an  essential  feature  of  either  procedure  that  the  stomach  be  thoroughly 
washed  out  before  the  operation  and  that  no  food  be  taken  for  at  least  twelve 
hours  preceding  the  anffisthetic.  For  washing  out  the  stomach,  the  ordinary 
oesophageal  tube  and  pump  or  the  stomach  siphon  may  be  used. 

Wounds. — In  the  treatment  of  gunshot  or  other  penetrating  wounds  of  the 
stomach,  the  incision  will  be  determined  in  a  measure  by  the  location  of  the  wound 
of  entrance.  As  a  general  proposition,  the  whole  stomach  area  may  be  best  ex- 
posed by  an  incision  which  splits  the  left  rectus,  beginning  about  half-way  between 
the  umlailicus  and  the  xiphoid  cartilage,  and  which  may  be  enlarged  as  neces- 
sary. When  more  room  is  required,  lateral  retraction  uj)on  the  recti  muscles, 
when  one  or  the  other  is  split  or  when  the  median  incision  is  made,  may  be  in- 
presised  by  dividing  transversely  the  muscle-sheath  which  allows  the  uncut  fibers 

379 


380 


THE   STOMACH 


to  stretch.     Should  the  lesion  be  near  the  cardia  and  otherwise  inaccessible,  the 
Meyer  costoplastic  procedure  may  be  necessary. 

The  stomach  should  be  dra^v^l  up  into  the  wound  as  far  as  possible,  the  opening 
in  the  anterior  wall  temporarily  clamped  to  prevent  further  extravasation,  while  the 


Fig.  444. — (After  Maclise.) 


colon  and  omentum  are  rolled  up  and  search  made  for  the  posterior  wound.  If  this 
is  found  it  should  be  clamped,  all  extravasated  matter  carefully  removed,  and  disin- 
fection made  with  swabs  moistened  in  1-3000  mercuric-chloride  solution,  followed 
immediately  by  the  free  use  of  hot  salt  solution.     The  question  of  packing  or 


THE  STOMACH  381 

draining  must  depend  upon  tlie  conditions  present.  If  in  serious  doubt  as  to 
infection,  it  is  wiser  to  lean  to  tlie  safer  side  of  drainage,  notwithstanding  tlie 
objectionable  featiires  of  the  adhesions  which  are  apt  to  follow.  In  closing  wounds 
of  the  stomach,  a  moderate-sized  pistol-shot  opening  may  be  closed  with  a  very 
carefully  inserted  purse-string  suture  of  chromicized  catgut,  reenforeed  by  a 
Gushing  linen  peritoneal  mattress  suture,  or  when  great  haste  is  required  a  single 
purse-string  suture  of  linen  (somewhat  less  safe)  will  suffice.  The  anterior  wound 
should  be  treated  in  the  same  way. 

In  the  case  of  incised  wounds  or  large  punctures,  the  Mayo  muco-serous  and 
the  Gushing  musculo-serous  sutures  are  advised. 

When  extensive  injuries  have  been  inflicted  upon  the  walls  of  the  stomach, 
after  closing  any  posterior  points  of  leakage  and  instituting  packing  or  draining, 
as  may  be  necessarjr,  in  order  to  give  the  greatest  possible  degree  of  rest  to  the 
organ  during  the  process  of  repair  and  at  the  same  time  to  insure  the  patient's 
nourishment,  a  temporary  gastrostomy  may  be  done.  If  the  anterior  penetrating 
wound  be  favorably  situated,  this  opening  may  be  utilized  by  carefully  stitching 
the  peritonaeum  of  the  abdominal  wall  to  that  of  the  stomach,  so  that  no  leakage 
into  the  peritoneal  cavity  may  occur.  Supporting  sutures  of  No.  1  or  No.  2 
linen  should  be  carried  through  the  entire  thickness  of  the  stomach  wall,  external 
to  the  peritoneal  row  of  stitches,  and  the  needle  then  carried  through  the  integu- 
ment around  the  margins  of  the  superficial  incision. 

In  these  rare  emergencies  the  insertion  of  a  soft-rubber  tube  through  this  open- 
ing and  beyond  the  pylorus  will  permit  the  introduction  of  nourishment  to  the 
duodenum  and  small  intestine  without  risk  to  the  posterior  wound  in  the  stomach 
wall. 

Should  this  procedure  be  deemed  inexpedient,  colon  alimentation  should  be 
relied  upon  for  a  week  or  ten  days  after  the  operation.  Under  favorable  condi- 
tions, liquids  in  very  small  quantities  may  be  given  by  the  mouth  after  three  or 
four  days.  It  is  safer,  however,  to  rely  upon  nourishment  by  the  rectum  until  tlie 
wounds  in  the  stomach  wall  have  safely  healed. 

Ulcer. — Ulcers  of  the  stomach  may  be  divided  clinically  into  two  classes :  The 
acute,  superficial  erosion,  limited  to  the  first  few  layers  of  lining  epithelia,  and  the 
deep  or  chronic  ulcer,  occasionally  round  in  shape,  more  often  with  jagged,  irregu- 
lar outlines,  which  invades  all  of  the  mucous  coat,  involves  the  muscle,  producing 
with  or  without  perforation  a  general  or  local  peritonitis. 

The  superficial  idcer  is  difficult  of  recognition,  and  unless  discovered  by  the 
gastroscope  it  may  heal  without  attracting  especial  attention,  and  often  without 
recurrence.  It  is,  however,  prone  to  recur,  and  unless  proper  treatment  is  insti- 
tuted will  merge  gradually  into  the  chronic  form. 

One  of  the  occasional  symptoms  of  superficial  ulcer  is  hemorrhage,  usually 
slight.  It  occurs  in  individuals  of  low  resistance,  and  is  apt  to  follow  an  abrasion 
of  the  epithelial  lining  caused  by  hard  ingesta,  the  broken  surface  becoming  more 
and  more  irritated  in  the  presence  of  hyperacidity. 

Insufficient  mastication  and  overingestion  are  in  all  prol)ability  the  principal 
factors  in  causing  the  production  of  gastric  idcer. 

Since  it  is  much  more  common  in  men  than  in  women,  the  inference  seems 
clear  that  overeating,  induced  by  the  indulgence  in  drinks,  has  an  important 
bearing  in  the  etiology.  It  is,  however,  not  infrequent  in  infants.  Between  the 
ages  of  seven  and  thirteen  it  is  not  at  all  rare.  (Prof.  A.  Jacobi,  Albany  Medical 
Annals,  June,  1907.) 

Chronic  idcers  may  be  recognized  by  the  feeling  of  distress  which  is  always 
constant  after  eating,  even  when  a  small  quantity  of  food  is  taken.  This  distress 
gradually  develops  into  well-marked  pain,  often  intensely  cramplike  in  character. 
There  is  tenderness  or  extreme  pain  on  direct  pressure,  especially  over  the  pyloric 
end.  Nausea  and  vomiting  are  the  common  indications  of  the  progress  of  this 
lesion,  and  are  usually  present  fifteen  or  thirty  minutes  after  ingestion.  With 
these  earlier  symptoms,  the  later  occurrence  of  hfemorrhage  points  with  almost 
unerring  certainty  to  ulcer. 

The  endoscope^  an  instrument  which  should  prove  of  inestimable  service  in 


382  THE  STO]VIACH 

the  early  recognition  and  the  prompt  and  intelligent  medical  treatment  of  these 
lesions,  should  be  employed  as  an  aid  in  diagnosis  as  well  as  in  treatment.  The 
one  laboratory  diagnostic  test  of  value  is  the  presence  of  high  values  of  hydro- 
chloric acid,  which  indicate  ulcer,  while  low  values  suggest  cancer   (W.  J.  Mayo). 

As  to  location,  ninety-four  per  cent  of  all  ulcers  are  on  the  pyloric  side  of 
Mayo's  line  (a  perpendicular  let  fall  from  the  cardiac  orifice),  and  of  these  over 
seventy  per  cent  occupy  the  lesser  curvature  and  the  posterior  wall. 

Treatment. — The  medical  treatment  of  ulcer  of  the  stomach  requires  a  perfect 
rest  of  this  organ.  This  can  only  be  secured  bj^  colon  alimentation,  and  if  after 
from  four  to  eight  weeks  of  this  careful  treatment  with  lavage  and  local  remedies 
the  symptoms  of  gastric  distress  are  not  relieved,  an  exploratory  incision  sliould 
be  made  in  the  median  line  half-way  between  the  umbilicus  and  xiphoid  cartilage. 
This  should  be  large  enough  to  permit  the  introduction  of  at  least  two  fingers  for 
careful  palpation  of  this  organ  and  for  inspection. 

In  properly  selected  cases  this  exploration  can  be  made  with  cocaine  infiltra- 
tion, provided  that  the  abdominal  peritonseum,  which  is  very  sensitive,  is  well 
antesthetized;  or  nitrous-oxide  gas  with  oxygen  or  air  will  be  found  entirely  satis- 
factory in  these  shorter  operations.  If  from  the  finding  a  more  extensive  pro- 
cedure is  necessary,  ether  narcosis  may  be  superadded.  By  inspection,  chronic 
iilcer  of  the  stomach  is  easilj'  recognized  by  the  induration  which  is  present  and 
the  milky  opaque  api^earance  of  the  peritoneal  covering. 

While  in  sudden  licBinorrhage  or  perforation  an  immediate  operation  is  im- 
perative, in  all  other  cases  a  patient  should  be  carefully  prepared.  Lavage  with 
the  stomach  tube  should  be  sj'stematically  performed  for  at  least  a  week  before 
the  operation,  and  during  this  period  the  patient  should  be  fed  with  tlie  most 
nourishing  and  readily  assimilated  articles  of  food.  Should  the  conditions  of  this 
organ  centra-indicate  ingesta,  colon  alimentation  should  be  practiced. 

Should  an  ulcer  be  discovered,  its  free  excision  is  demanded,  and  since  ulcers 
are  frequently  multiple  and  often  coalesce,  a  partial  gastrectomy  should  not  be 
begun  until  other  lesions  are  located  or  excluded  by  inspection. 

In  multiple  ulcer  it  is  often  safer  and  easier  to  excise  a  considerable  portion 
of  the  stomach  wall  than  to  attempt  a  separate  excision  of  several  lesions. 

The  operation  consists  in  a  rapid  enlargement  of  the  incision  through  the 
abdominal  wall,  bringing  the  stomach  forward  into  the  wound,  and  a  careful  pro- 
tection of  the  peritoneal  cavity  from  infection  by  the  escape  of  gastric  contents. 
Sterile  mats  taken  from  hot  normal  salt  solution  should  be  inserted,  carefully  iso- 
lating the  operative  field,  while  clamps  guarded  by  soft-rubber  tubing  should, 
when  possible,  be  applied  in  such  manner  as  to  control  hemorrhage  during  the 
operation  and  prevent  leakage  from  the  cavity  of  the  organ. 

The  entire  area  of  induration  should  be  excised  and  the  edges  united,  prefer- 
ably in  a  direction  at  right  angles  to  the  long  axis  of  the  stomach,  employing 
the  preliminary  through-and-through  catgut  muco-serous  stitch  of  C.  H.  Mayo, 
reenforced  by  the  sero-muscular  mattress  sutures  of  H.  W.  Gushing.  The  technic 
of  these  sutures  is  thoroughly  demonstrated  in  Fig.  445a. 

Should  it  become  necessary  to  perform  gastrectomy ,  the  area  to  be  excised 
having  been  determined  by  careful  examination,  the  gastrocolic  and  gastrohepatic 
omenta  are  tied  off  with  catgut  sutures  as  far  as  the  disease  extends,  and  "  a 
straight  elastic  holding  clamp  is  placed  on  the  proximal  side  across  from  the 
greater  to  the  lesser  curvature  about  one  inch  back  from  the  proposed  line  of  sec- 
tion. On  the  distal  side  the  clamp  is  applied  obliquely  from  above  down,  right 
to  left,  to  increase  the  diameter  of  the  cut  surface,  saving  from  the  greater  curva- 
ture. In  this  way  we  have  beenjible  to  secure  on  the  distal  side  an  opening  two 
thirds  the  size  of  the  proximal  one  for  suturing.  By  having  one  inch  or  more 
of  the  tissue  projecting  beyond  the  clamps,  the  slack  on  the  large  or  proximal 
side  is  taken  up  with  each  suture,  the  bits  of  the  thread  taking  only  two  thirds 
of  the  amount  of  tissue  on  the  distal  portion,  a  diiference  in  diameter  of  one  third 
being  disposed  of  without  seam  or  puckering.  If  the  ulcer  is  situated  close  to 
the  pylorus,  an  end-to-end  union  is  quite  easy  to  obtain"  (AV.  J.  Mayo).  The 
division  should  be  made  by  a  clean  cut  with  long  straight  scissors  or  a  sharp  knife. 


THE  STOMACH 


383 


In  vie-w  of  tlie  improved  teclmic  and  the  insignificant  death-rate  which  in 
careful  and  expert  hands  follows  this  procedure,  when  any  lesion  of  the  stomach 
(especially  at  the  pyloric  end,  where  practically  all  begin)  requires  an  excision 
the  closure  of  which  causes  deep  puckering  or  hour-glass  contraction,  a  resection 
which  includes  the  diseased  area  in  its  zone  as  advocated  by  Prof.  W.  L.  Eodman 
is  advised. 

If  direct  reunion  is  not  easily  accomplished,  the  open  ends  should  be  closed 
and   gastro-jejunostomy   performed.      Should    the    operator    prefer   gastro-duode- 


FiG.  445. — Showing  lines  of  section  in  partial  gastrectomy  for  large  ulcer.      The  gastro-hepatic  and 
gastrocolic  omenta  have  been  tied  off.      (Mayo.) 

nostomy,  the  technic  of  these  two  procedures  is  practically  identical.  As .  there 
is  only  five  inches  of  the  duodenum  below  the  entrance  of  the  common  duct,  and 
as  the  second  portion  of  this  gut  is  not  readily  movable,  the  "  no-loop  "  operation 
of  gastro-jejunostomy,  as  advised  by  W.  J.  Mayo,  is  to  be  preferred. 

Gastro-jejunostomy  is  also  indicated  where  rest  and  drainage  of  the  stomach 
is  necessary  to  restore  its  function,  where  stricture,  either  of  the  pylorus  or  of  the 
upper  two  or  three  inches  of  the  duodenum  or  the  last  several  inches  of  the 
stomach  exists,  and  where  an  excision  with  immediate  end-to-end  anastomosis 
does  not  commend  itself  to  the  surgeon. 

In  this  operation  anastomosis  should  be  made  as  close  to  the  origin  of  the 


SS4 


THE  STOMACH 


jejunum  as  possible.  The  landmarks,  as  laid  down  by  W.  J.  Mayo  ("Annals  of 
Surgery,"  1906),  are  as  follows:  "The  origin  of  the  jejunum  is  at  the  point 
where  the  duodenum  passes  through  the  transverse  mesocolon  (Fig.  445&).  The 
distal  end  of  the  duodenum  lies  behind  the  stomach  when  the  latter  is  moder- 


FiG.  445a. — Showing  the  excision  accomplished,  the  clamps  in  position  and  the  teclinic  of  tlie  Gush- 
ing musculo-serous  suture  near  tlie  lesser  curvature  and  the  Mayo  sero-mucous  suture  below. 
(Mayo.) 

ately  distended,  and  abotit  one  and  a  half  inches  to  the  left  of  the  middle  line 
and  from  one  and  a  half  to  two  inches  above  the  umbilicus.  The  duodeno-jejunal 
juncture  is  within  about  two  inches  as  high  as  the  pylorus.  It  is  here  directed 
upward  and  to  the  left.  The  jejunum  from  this  origin  drops  at  once  into  the 
left  abdominal  fossa,  gravitating  backward  to  the  left  kidney,  underneath  the 
splenic  flexure  of  the  colon.  .  The  proper  site  for  gastric  incision  is  somewhat 
to  the  left  of  a  line  let  fall  perpendicularly  from  the  cardiac  orifice  of  the  stomach. 
(See  Fig.  44.5&.)  The  operation  now  recommended  is  figured  in  the  accompany- 
ing illustration.  Anastomosis  is  direct,  without  looping  the  jejunum — the  "  no- 
loop  "  operation.     The  following  is  the  technic  of  the  Mayos : 

"  Steps  of  the  Operation. — For  benign  disease  the  abdomen  is  opened   from 
three  fourths  to  one  inch  to  the  right  of  the  median  line,  splitting  the  fibers  of 


THE  STOMACH 


385 


the  rectus  muscle.  The  transverse  colon  is  drawn  out  of  the  abdominal  incision 
and  by  a  steady  traction  to  the  right  and  upward  the  mesocolon  is  brought  out 
until  the  jejunum  comes  into  view,  and  the  intestine  is  grasped  at  a  point  three 
or  four  inches  from  its  origin.  On  drawing  the  jejunum  tight  the  fold  of  peri- 
tonjeum  which  covers  the  ligament  of  Treitz  (a  small  band  containing  muscle 
fibers)  is  developed.  This  peritoneal  band  has  its  origin  on  the  transverse  meso- 
colon and  extends  down  on  to  the  beginning  of  the  jejunum,  acting  as  a  sus- 
pensory ligament;  it  will  be  found  to  lead  to  the  base  of  the  vascular  arch  of 
the  middle  colic  artery,  and  accurately  marks  the  place  where  the  transverse  meso- 
colon is  torn  through  to  secure  the  posterior  wall  of  the  stomach  (Fig.  445c).    The 


Fig.  4456. — Showing  the  location  of  the  opening  of  communication  between  the  stomacli  and  jejunum 
in  posterior  "no-loop"  gastro-jejunostomy.  The  dotted  lines  represent  the  last  portion  of  the 
duodenum  and  the  jejimum  as  tliey  lie  behind  the  transverse  colon  the  stomach  and  the  gastro- 
colic omentum.      (Mayo.) 


stomach  is  drawn  through  this  opening  and  the  anastomosis  performed,  beginning 
at  a  point  one  inch  above  the  greater  curvature  on  a  line  with  the  longitudinal 
portion  of  the  lesser  curvature  and  ending  at  the  bottom  of  the  stomach,  two  and 
one  half  inches  to  the  left.  To  secure  a  proper  low  point  a  small  opening  is  made 
in  the  gastrocolic  omentum  and  one  half  inch  of  the  anterior  wall  pulled  through 
behind.     Having  these  features  in  view  a  considerable  portion  of   the  posterior 


386 


THE  STOMACH 


■wall  is  drawn  into  a  pair  of  light  elastic  curved  holding  clamps.  We  prefer  the 
Doyen  (Fig.  445(Z).  The  handles  lie  to  the  right  and  about  transverse  with  the 
axis  of  the  body.  Beginning  one  and  one  half  to  three  and  one  half  inches  from  its 
origin,  the  jejunum  is  drawn  into  a  similar  pair  of  clamps  with  handles  to  the  right. 


/       ./ 


Fig.  445c. — The  transverse  colon  is  lifted,  the  mesocolon  perfomtod,  and  a  portion  of  the  posterior  wall 
of  the  stomach  drawn  through  and  held  by  forceps.  The  dotted  lines  indicate  the  direction  of  the 
opening  of  communication.  The  ligament  of  Treitz  is  seen  between  the  stomach  and  jejunum. 
(Mayo.) 

It  will  thus  be  seen  that  the  left  low  point  on  the  stomach  lies  in  the  tip  of  the 
clamps  and  the  distal  point  of  the  jejunum  lies  also  to  the  left.  By  placing  the 
two   clamps   side  by   side   the   operation  is    completed   in   the   usual    manner   by 


THE  STOMACH 


387 


two-row  suturing,  chromic  catgut  suture  being  used  for  the  inner  through-and- 
through  mucous  stitch,  as  silk  or  linen  may  hang  ulcerating  for  months  before 
passing  away.  In  applying  this  suture  on  the  posterior  row  behind  wo  use  the 
Connell  or  huttonliole  suture.    On  the  anterior  we  use  the  method  advised  by  Dr. 


/M.JivUvo, 


Fig.  445d. — The  same  with  clamps  applied  preparatory  to  insertion  of  the  sutures.  In  the  trough  where 
the  stomach  and  jejunum  are  in  contact  the  Gushing  stitch  is  first  placed  for  the  length  of  contact. 
The  two  organs  are  then  incised  and  the  Mayo  suture  inserted  for  the  entire  circumference  of  the 
openings.     The  Gushing  stitch  is  then  completed.     (Mayo.) 

Charles  H.  Mayo,  which  consists  in  entering  the  needle  on  the  j^eritoneal  side 
through  to  the  mucous  and  directly  backward  from  mucous  to  peritonasum  on 
the  saiue  side.  By  doing  this  alternately,  first  on  one  side  and  then  on  the  other, 
with  this  first  chromic  catgut  suture  the  peritoneal  surfaces  are  rolled  into  con- 
tact, the  parts  to  be  united  are  held  firmly  in  apposition,  and  the  hasmorrhage 


388  THE  STOMACH 

checked.  The  outer  row  consists  of  No.  1  celluloid  linen  (Pagenstecher).  Flat- 
tening the  intestine  (Cannon  and  Blake)  should  be  avoided  by  grasping  the 
intestinal  wall  close  to  the  margin  of  the  incision  with  the  suture  so  as  to  turn 
in  a  narrow  seam  from  the  intestinal  side.  On  the  gastric  side,  on  the  contrary, 
there  need  be  no  hesitation  in  taking  a  free  grasp  of  the  tissues.  The  rent  in  the 
mesocolon  is  fastened  to  the  suture  line  with  three  or  four  mattress  sutures  of 
linen.  This  should  grasp  the  peritoneal  coat  close  to  the  margins  of  the  rent 
in  such  manner  that  when  tied  all  the  raw  surfaces  shall  be  turned  in  behind  the 
stomach,  and  the  peritonaeum  folded  smoothly  against  the  gastro-Jejunostomy 
opening  so  that  there  shall  be  nothing  to  cause  adhesions  to  form  between  the  meso- 
colon and  the  jejunum  beyond  the  anastomosis." 

While  in  the  hands  of  one  who,  by  reason  of  large  experience,  can  work  with 
rapidity  and  accuracy  in  performing  anastomosis  by  suture,  under  other  conditions 
the  employment  of  Murphy's  oblong  button  may  he  preferred. 

The  technic  is  as  follows :  After  the  jejunum  has  been  clamped  on  either  side 
of  the  point  where  the  incision  is  to  be  made,  two  floss  needles,  two  and  one  half 
inches  in  length,  on  a  single  thread  of  Pagenstecher  linen  or  silk  No.  3,  are  in- 


FiG.  445e. — The  same.  The  posterior  half  of  the  Gushing  suture  has  been  completed,  a  straight  incision 
has  been  made  into  the  cavity  of  botli  viscera,  the  C.  H.  Mayo  stitch  lias  been  superadded  and  is 
being  continued  along  the  entire  circumference  of  tlie  anastomosis.  Wlien  completed  the  remain- 
der of  the  Gushing  stitch  will  be  superadded.      (Mayo.) 


sorted  on  the  convex  portion  of  the  stomach  (or  bowel),  so  that  each  needle 
penetrates  the  wall  four  or  five  times  in  a  space  of  about  an  inch  and  a  quarter. 

They  should  be  a  qiurrter  of  an  inch  apart,  and  while  the  needles  are  still  in 
the  wall  of  the  bowel  or  stomach  a  scalpel  is  used  to  divide  the  wall  midway 
between  the  needles  for  the  distance  of  three  quarters  of  an  inch. 

A  tissue  forceps  then  grasps  the  entire  thickness  of  the  bowel  (or  stomach) 
at  the  needle-eye-end  of  the  incision,  and  the  needles  are  drawn  throttgh  until  the 
loop  comes  quite  up  to  the  forceps. 

One  half  of  the  oblong  button  (Pig.  446),  grasped  at  the  end  of  the  C3'lin- 
der  with  an  ordinary  hamostat,  is  then  slid  entirely  into  the  bowel  or  stomach, 
with  the  invaginating  tube  projecting  through  the  incision  (the  cap  entirely  within 
the  viscus). 

The  thread  is  then  tied  fairly  frm  only  on  the  intussuscipiens  or  inner  tube, 
and  the  thread  cut  short  close  to  the  cylinder. 


THE  STOMACH 


3S9 


The  button-holding  forceps  (Fig.  447)  is  then  apjolied  to  the  cylinder,  grasp- 
ing the  ends  and  extending  outward  at  right  angles  from  the  button,  and  pushed 
as  far  down  on  the  cylinder  as  the  tissue  will  permit. 

The  other  half  of  the  button  is  inserted  in  a  similar  manner,  and  the  other 
holding  forceps  applied  to  the  ends,  but  in  the  opposite  direction  from  the  first,  so 
that  when  the  buttons  are  approximated,  one  holding  forceps  will  be  to  the  right 
and  one  to  the  left  of  the  operator. 

The  holding  forceps  then  twists  the  button 
around  into  position  and  the  cylinders  are  in- 
vaginated. 

The  holding  forceps  of  the  inner  cylinder  is 
removed  first,  so  as  to  permit  it  to  invaginate 
and  catch  in  the  outer  cylinder. 


-Mun:ihy's  obloni 
and  key. 


button        Fig.  447. — Murphy 


Then  the  other  holding  forceps  is  removed  and  the  biitton  is  slowly  pressed 
home,  until  there  is  a  firm  compression  of  the  cups. 

The  reason  that  the  thread  on  the  inner  cylinder  is  not  tied  so  tight  as  on 
the  outer  cylinder  is  that  on  invaginating  it  it  is  desirable  that  the  outer  tube 
can  pass  between  the  thread  and  the  inner  cylinder. 

To  relieve  the  approximated  surfaces  of  tension,  one  or  two  catgut  sutures 
should  now  be  inserted  one  third  to  one  half  inch  from  the  button,  so  as  to  prevent 
traction  during  the  process  of  repair. 

It  is  entirely  unnecessary  to  surround  the  button  with  a  row  of  sutures. 

In  doing  a  gastro-enterostomv.  Professor  Murphy  divides  the  stomach  wall  par- 
allel to  the  long  axis  of  the  vessels — i.  e.,  transverse  to  the  midline  of  the  stomach 
curvature — and  makes  the  approximation  as  near  to  the  pyloric  end  of  the  stomach 
as  the  anatomic  conditions  will  permit.  After  exposing  the  stomach  wall  through 
the  mesocolon,  the  edges  of  the  mesocolon  are  anchored  to  the  stomach  by  four 
stitches,  an  inch  or  an  inch  and  a  half  ajjart,  so  as  to  secure  a  complete  closure 
of  the  lesser  peritoneum  by  the  subsequent  agglutination  and  adhesions  of  the 
mesocolon  to  the  stomach. 

"As  the  ligament  of  Treitz  draws  the  first  portion  of  the  Jejunum  from  left 
to  right,  and  not  from  right  to  left  as  so  erroneously  stated,  I  always  make  the 
approximation  of  the  stomach  wall  nm  from  left  to  right  in  consonance  with 
the  normal  anatomic  direction  of  the  first  portion  of  the  jejunum. 

"  The  button  is  voided  in  gastro-enterostomies,  as  a  rule,  on  an  average  from 
the  eleventh  to  the  fifteenth  day.  In  side-to-side  unions  of  the  intestines  it  is 
usually  voided  earlier"   (Murphy). 

Oasiro-duodenostomy  is  recommended  in  those  cases  of  mucous  lesions  which 
interfere  with  p5doric  drainage  on  accoimt  of  spasm. 

Hour-glass  Stomach. — Gastroplastic  operations  for  the  relief  of  hour-glass 
contractions  are  not  satisfactorj',  and  resection  is  to  be  preferred.  After  expos- 
ing the  organ  by  the  incision  through  the  left  rectus,  it  is  drawn  up  through  the 
wound  and  the  gastrohepatic  and  gastrocolic  omenta  are  tied  ofE  as  shown  in 
Figs.  445  and  452. 

The  method  of  applying  the  clamps  and  of  suturing  is  indicated  in  Pig.  445a, 
where  at  B  on  the  lesser  curvature  is  shown  the  final  sero-muscular  stitch  of  Gush- 
ing, while  in  the  lower  portion  of  the  wound  the  muco-serous  suture  of  C.  H. 
Mayo  is  in  process  of  insertion.     The  posterior  wall  is  first  united  by  the  Mayo 


390 


THE   STOMACH 


stitch,  the  Gushing  sntiire  being  superadded,  and  then  the  anterior  wall  of  the 
stomach  is  sutured,  thus  completing  the  entire  circumference  of  the  organ. 

When  the  closure  shall  have  been  completed,  the  forceps  removed,  and  a  careful 
toilet  performed,  the  rents  in  the  gastrohepatic  and  gastrocolic  omenta  should  be 
reunited  with  catgut  sutures  in  such  a  way  that  adhesions  will  not  be  possible. 
The  technic  here  described  is  applicable  to  the  removal  of  a  part  of  one  wall  or 
to  complete  section. 

Gastro-pylorectoviy,  an  operation  formerly  done  for  pyloric  stenosis  with  lim- 
ited cicatricial  narrowing  of  the  pyloric  end  of  the  stomach,  is  now  practically 
abandoned.  The  suture  of  the  duodenum  to  the  lower  portion  of  the  opening  in 
the  stomach  wall  left  a  point  at  which  leakage  was  always  an  element  of  great 
danger.  The  better  procedure  is  to  close  separately  the  upper  ends  of  the  duo- 
denum and  the  stomach,  as  shown  in  Fig.  454,  and  perform  a  separate  no-loop 
gastro-jcjunostomy,  as  recommended  by  Rodman  and  Mayo. 

Adliesions  of  the  stomach  to  the  abdominal  wall,  the  colon,  duodenum,  or 
other  contiguous  viscera,  are  occasionally  met  with.  As  they  limit  the  peristalsis 
of  the  stomach,  they  interfere  seriously  with  digestion  and  demand  operative  inter- 
vention. Incision  through  the  left  rectus  is  indicated,  the  adhesions  should  be 
separated,  and  if  possible  the  raw  surfaces  should  be  covered  by  direct  peritoneal 
suture  or  by  stitching  a  layer  of  omentum  over  the  exposed  surfaces.  In  several 
instances  where  neither  of  these  methods  was  availalile.  Van  Buren  Knott  has 
successfully  employed  Cargile  membrane. 

In  the  rare  instances  when  duodcno-gastroplasty  is  required,  the  pylorus  is  ex- 
posed Ijy  splitting  the  right  rectus  with  any  of  the  modifications  already  given 
for  a  wider  opening.  The  visceral  incision  usually  extends  from  an  inch  to  an 
inch  and  a  half  in  the  stomach  tissue  and  the  same  distance  over  the  pylorus  into 
the  duodenum.     The  stricture  is  divided  in  this  incision,   and  the  posterior  in- 


Fio.  448. — Incision  in  duodeno-gastroplasty.     (From  Park's  "Surgery.") 

ternal  surface  of  the  wall  of  the  stomach,  the  i:)ylorus,  and  duodenum  are  brought 
well  into  view  by  inserting  a  tenaculum  above  and  below  in  the  center  of  the  incir 
sion,  and  widely  separating  the  edges  of  the  wound.  Holding  the  wound  thus 
open  in  diamond  shape,  the  duodenum  is  brought  over  upon  the  stomach  and 
Mayo-Cushing  sutures  are  inserted,  beginning  at  the  upper  and  lower  angles  made 
by  retraction  with  the  tenacula.  The  duodenum  is  folded  over  and  sewed  on  to 
the  opening  in  the  stomach  in  such  a  way  that  a  stricture  no  longer  exists,  tlie 
contents  of  the  stomach  falling  directly  into  the  duodenum  beyond  the  pylorus. 
Should  any  difficulty  be  experienced  in  uniting  the  edges  of  this  longitudinal 
incision,  excision  of  the  pylorus  and  direct  end-to-end  siiture  should  be  sub- 
stituted. 

Gastropiosis,  or  falling  of  the  stomach,  is  due  to  the  stretching  of  the  gastro- 
hepatic omentum  from  inherent  weakness  of  this  structure,  general  relaxation  or 
atony  of  the  muscle  due  to  malnutrition  and  to  overloading  and  distention  of  this 
organ,  and  transverse  colon,  which  aids  in  the  downward  displacement  of  the 
stomach. 


THE   STO^UCH 


391 


The  diagnosis  of  displaced  stomach  can  be  determined  by  careful  percussion 
combined  -nith  auscultation.  The  greater  curvature  can  be  made  out  by  having 
the  patient  drink  a  considerable  quantity  of  ■(vater  upon  an  empty  stomach.  The 
percussion  notes  will  give  the  water  level  as  distinguished  from  the  tympanitic 
resonance  of  the  intestinal  tract.  Oscillation  will  elicit  a  gurgling  sound  of  the 
liquid  contents.  Hj-perdistention  of  the  displaced  and  iisually  dilated  organ  by 
swallowing  air,  or  by  the  administration  of  a  gas-producing  powder,  will,  by  per- 
cussion notes,  give  the  upper  and  lower  outlines  of  the  organ.  With  these  objec- 
tive symptoms  there  are  subjective  signs  of  indigestion  or  gastric  distress,  since 
it  is  difficult  for  the  stomach  to  discharge  its  contents  through  the  pylorus. 


Fig.  449. — The  same  after  suture.     (From  Park's  "Surgery.") 


The  operative  methods  look  to  the  shortening  of  the  gastrohepatic  omentum. 
As  a  rule,  this  is  thin  and  difficult  of  successful  replication.  The  operation  of 
F.  S.  Eve  ^  commends  itself,  and  is  as  follows : 

A  free  incision  is  made  through  the  rectus  muscle,  one  inch  to  the  left  of  the 
(patient's)  median  line.  A  sand-bag  placed  beneath  the  back,  opposite  the  stom- 
ach, raises  the  liver  and  holds  it  out  of  the  way.  Celluloid  linen  sutures,  five  or  six 
in  number,  are  now  inserted  through  the  lesser  curvature  of  the  stomach,  taking 
firm  hold  on  the  muscle  and  serous  covering  but  avoiding  in  their  grasp  the 
blood  supply  of  the  lesser  curvature.  The  needle  is  next  carried  through  the  at- 
tachment of  the  lesser  omentum  to  the  liver,  taking  hold  quite  deeply  in  the 
liver  substance.  The  stomach  is  then  lifted  so  as  to  bring  the  lesser  curvature  in 
contact  with  the  under  surface  of  the  liver,  and  the  sutures  are  tied.  Eve  sug- 
gests (and  has  carried  out  the  suggestion)  that  when  the  liver  has  also  been 
dragged  downward,  the  passage  of  a  series  of  interrupted  sutures  through  the 
anterior  surface  of  the  left  lobe,  and  then  through  the  margin  of  the  costal  car- 
tilages, wUl  hold  the  liver  in  a  more  nearly  normal  position  and  give  an  additional 
guarantee  to  the  anchorage  of  the  stomach. 

GastropUcation. — When  the  stomach  muscle  has  been  hopelessly  stretched  and 
weakened  by  prolonged  neglect  and  overdistention,  this  operation  -may  at  times 
be  beneficiai.  It  consists  in  exposing  the  organ  by  splitting  the  left  rectus,  bring- 
ing the  stomach  forward  into  or  through  the  incision  if  possible,  laying  a  long 
steel  urethral  sound  parallel  with  its  long  axis,  folding  the  peritoneal  surfaces 
over  this  instrument  and  introducing  chromicized  catgut  sutures,  as  shown  in 
Fig.  450.     Several  parallel  rows  of  these  sutures  may  be  required. 

Hernia  of  the  stomach  is  one  of  the  rarest  accidents  to  this  organ."  The  diag- 
nosis can  only  be  assured  by  exploration.  The  indications  are  reduction  of  the 
hernia  and  closure  of  the  opening.  If  through  the  diaphragm  by  chromicized 
catgut  sutures,  and  in  reaching  the  vault  of  the  diaphragm  the  osteoplastic  sec- 
tion of  the  costal  arches,  as  advised  by  Prof.  Willy  Meyer,  may  be  necessary.  If 
through  the  alxlominal  wall,  direct  incision  and  closure  is  indicated. 

>  "British  Med.  Journal,"  April  7,  1906;   "General  Surgery,"  Murphy,  1907, 
'G.  S.  Gordon,  M.D.,  "Annals  of  Surgery,"  May,  1907. 


392 


THE  STOMACH 


Carcinoma. — The  causative  relation  between  ulcer  and  cancer  of  the  stomach 
is  evident  from  the  fact  that  the  latter  almost  always  occurs  in  that  portion  of 
the  organ  where  ulcer  is  common. 

In  1890,  48,  and  in  1900,  60  per  100,000  died  from  this  disease  in  the  United 
States.     The  age  limit  varied  from  thirty-one  to  seventy-five  years,  it  being  most 


Fig.  450. — Gastroplication  (Weir's  modification  of  Bircher's  operation) ;  I.  A,  Sound  infolding  an- 
terior stomacli-wall ;  B,  B,  First  tier  of  Lembert  sutures  burying  in  sound;  C,  Second  tier  of 
sutures  ready  to  bury  in  sound  for  second  time,  when  latter  is  placed  upon  first  tier.  II.  Sectional 
view  of  stomach  after  the  two  tiers  have  been  tied.     (Bickham.) 


frequent  from  forty  to  sixty.  In  very  rare  instances  it  has  occiirred  under  the 
twentieth  year  of  life  (W.  Gilman  Thompson).^ 

The  ratio  of  mortality  will  only  be  materially  decreased  when  greater  intelli- 
gence is  shown  in  our  methods  of  nutrition,  and  when  by  means  of  the  gastro- 
scope  and  the  careful  analysis  of  symptoms  ulcer  is  recognized  in  its  earlier  stages 
and  subjected,  to  skillful  medical  and  dietetic  treatment. 

Diagnosis. — In  delayed  cases  the  enlargement  and  induration  may  be  recog- 
nized by  palpation.  The  patient  should  be  seated  leaning  forward  in  comi^lete 
relaxation  of  the  abdominal  muscles,  with  the  knees  drawn  up,  thus  allowing  the 
stomach  to  fall  to  the  lowest  possible  level.  At  times  when  no  tumor  may  be 
felt,  gastric  tenderness,  as  shown  by  muscular  rigidity,  is  a  strong  indication  of  an 
underlying  lesion   (W.  Gilman  Thompson). 

According  to  Thompson: 

"  Loss  of  muscular  strength  and  weight,  even  without  definite  phenomena,  are 
among  the  most  constant  early  symptoms,  but  bear  no  definite  proportion  to  the 
size  or  position  of  the  growth.  Dilatation  of  the  stomach,  developing  rather  sud- 
denly, suggests  pyloric  cancer.  Failure  to  improve  radically  under  treatment  is 
an  important  diagnostic  indication.     As  to  the  blood  examination,  the  early  char- 

«  "Ohio  State  Medical  Journal,"  1907. 


THE  STOMACH  393 

acteristics  are  a  moderate  leucocytosis  (13,000  to  16,000),  pol}Tiucleosis,  moderate 
anaemia,  with  red  cells  rarely  below  3,000,000,  and  hemoglobin  sixty  per  cent. 

"  Vomiting  is  an  early  symptom  in  a  large  number  of  cases,  not  infrequently 
with  hsematemesis.     The  stools  should  be  examined  for  occult  blood. 

"  Epigastric  pain  is  a  variable  symptom.  The  analysis  of  gastric  contents 
should  be  several  times  repeated  before  arriving  at  a  conclusion.  The  dread  of 
the  first  passage  of  the  stomach  tube  may  inhibit  secretion.  The  variations  from 
hyperacidity  to  hypoacidity  differ  in  other  lesions  as  they  do  in  gastric  cancer." 
(Thompson.)  ^ 

Gastrectomy  for  Cancer. — In  an  operation  of  itself  formidaljle,  and  rendered 
more  grave  by  reason  of  the  low  resistance  which  insufficient  nourishment  induces 
the  smallest  possible  quantity  of  ether  should  be  given.  In  view  of  the  fact  that 
the  stomach  is  entirely  insensible  to  pain,  and  that  the  abdominal  peritonfeum  is  the 
only  exquisitely  sensitive  tissue  involved,  the  skillful  combination  of  morphia, 
nitrous  oxide  gas  and  ether,  with  the  employment  of  sequestration,  should  secure 
a  jperfect  ansesthesia  with  the  minimum  of  ether. 

The  following  technic  of  W.  J.  Mayo  is  preferred: 

1.  Exploration. — A  short  incision  is  made  in  the  midline  half-way  between  the 
umbilicus  and  the  ensiform  cartilage.  Two  fingers  are  introduced  and  the  growth 
explored  with  reference  to  other  structures.  Next  the  extent  of  glandular  involve- 
ment is  ascertained  (Fig.  451).  If  the  case  seems  fairly  reasonable  for  operation, 
the  incision  is  rapidly  enlarged  and  the  growth  drawn  out  of  the  abdomen.  This 
manoeuvre  permits  of  careful  examination  of  the  lesser  curvature,  and  especially 
as  to  whether  the  infiltration  in  this  vicinity  extends  beyond  the  possibility  of 
removal.  The  transverse  mesocolon  is  then  inspected,  as  it  is  often  infiltrated 
from  behind.  The  posterior  surface  of  the  stomach  and  its  relation  to  the  pancreas 
are  palpated  with  fingers  passed  through  a  rent  in  the  gastrohepatic  omentum. 

2.  Mohilization  of  the  Lesser  Curvature  (Fig.  4.52). — The  stomach  is  drawn 
firmly  dowTiward  and  to  the  right,  the  left  lobe  of  the  liver  raised  by  the  fingers 

'  This  author  gives  the  following  summary  of  conditions  which  combine  to  make  operation 
desirable.  I  cannot  but  insist  that  since  delay  is  the  gravest  of  all  surgical  dangers  any  doubt  as 
to  the  exact  character  of  the  lesion  should  lean  to  the  side  of  exploration. 

1 .  The  patient's  age  should  be  within  the  average  cancer  developing  period,  for  gastric  cases, 
i.  e.,  between  forty  and  sixty-five  years. 

2.  There  should  be  a  rapid  and  decided  loss  of  weight  and  strength,  without  other  assignable 
cause,  such  as  chronic  gastric  catarrh,  neurasthenia,  mental  strain  or  worry,  or  chronic  general 
disease,  such  as  diabetes,  etc. 

3.  There  should  be  evidence  of  some  degree  of  stagnation  of  food  contents  .in  the  stomach. 

4.  There  should  be  failure  to  improve  in  marked  degree  under  treatment  after  a  few  weeks' 
trial. 

With  these  four  conditions  fulfilled,  exploration  should  be  seriously  considered,  despite  the 
absence  of  gastric  pain  or  other  marked  gastric  symptoms.     In  addition  there  may  be: 

5.  A  leucocytosis  of  12,000  to  15,000  with  polynucleosis  and  a  moderate  secondary  anaemia, 
with  low  color  index. 

6.  Decided  dilatation  of  the  stomach. 

With  these  two  additional  factors,  operation  is  distinctly  indicated.     Still  further  there  may  be: 

7.  Occasional  attacks  of  vomiting  without  definite  relation  to  food  ingestion. 

8.  Occult  or  visible  blood  in  the  vomitus  or  stools. 

9.  Epigastric  or  right  hypogastric  rigidity  and  tenderness  on  deep  pressure. 

With  these  symptoms  added,  the  diagnosis  can  admit  of  practically  no  question.  In  this 
order  of  relative  importance  of  symptoms  I  have  purposely  left  vmtil  the  last,  as  being  often 
imreliable: 

10.  The  demonstration  of  hypoacidity  or  anacidity,  and 

11.  The  so-called  carcinomatous  cachexia,  which,  while  plain  enough  toward  the  fatal  ending, 
is  often  wanting  as  an  early  definite  appearance. 

By  thus  grouping  the  train  of  symptoms  and  conditions  in  the  relative  order  of  their  appearance 
and  importance,  it  becomes  possible  to  recommend  operation  at  a  period  when  there  is  hope  cf 
accomplishing  something  more  definite  than  mere  exploration.  As  to  what  is  to  be  gained  by 
early  operation,  there  is  first  always  the  relief  of  uncertainty  as  to  the  extent  and  nature  of  the 
disease,  and  as  to  any  possibility  of  error  in  diagnosis.  Second,  there  is  the  possibility  of  com- 
plete extirpation  of  the  growth  and  the  prolongation  of  life  for  three  or  four  years  before  a  fatal 
and  inoperable  return.  Third,  there  is  the  certainty  not  only  of  some  prolongation  of  life,  but 
of  relief  from  much  increasing  suffering,  and  particularly  from  that  most  wretched  of  deaths,  by 
slow  starvation,  with  constant  nausea,  regurgitation  and  pain  from  a  dilated  and  useless  stomach. 
Even  in  the  later  cases  in  which  a  growth  of  considerable  size  is  obvious,  operation  may  be  of  ad- 
vantage as  a  palliative  measure  whenever  the  growth  obstructs  the  pylorus,  causing  dilatation. 


394 


THE   STOMACH 


of  an  assistant,  and  the  gastric  artery  tied  witli  catgut  on  a  needle  at  the  highest 
possible  point  well  beyond  the  lymphatic  nodes.  A  pair  of  clamps  are  caught  on 
the  opposite  side,  and  the  artery  and  that  portion  of  the  gastrohepatic  ligament 
which  has  been  ligated  with  it  are  cut.  With  a  few  nicks  of  the  knife  the  pedicle 
is  partly  detached  from  the  stomach  and  allowed  to  retract.  This  permits  of 
mobilization  of  the  gastric  wall  and  obtains  a  clear  space  near  the  resophagus 
for  the  division  of  the  stomach.  The  superior  pyloric  artery  and  the  remainder  of 
the  gastrohepatic  ligament  are  now  doubly  tied  and  cut  between,  leaving  the  glands 


Fig.  451. — Showing  the  Une  of  section  through  the  stomach  beyond  the  infiltration  of  the  glands  in 
tlie  gastro-liepatic  and  gastro-colic  omenta.  The  Uver  is  lifted  to  e.xpose  the  lesser  curvature 
and  the  gastro-hepatic  omentum.     (Mayo.) 


attached  to  the  duodenum.     This  mobilizes  the  entire  lesser  curvature  and  makes 
the  remainder  of  the  work  outside  of  the  body. 

3.  Separation  of  the  Pyloric  End  of  the  Stomach. — The  hand  is  passed  into  the 
lesser  cavity  of  the  peritoneum  behind  the  stomach,  adhesions  are  carefully  divided, 
and  bleeding  points  ligated  (Fig.  452).  Hot  moist  gauze  pads  are  now  i^laced  in 
this  space.  Two  pairs  of  narrow  crushing  clamps  (Ferguson)  are  placed  on  the 
duodenmn  well  below  the  disease  (as  a  rule,  an  inch  below  the  pylorus)  and  the  duo- 
deniun  is  divided  between.  The  glands  lying  in  the  omentum  immediately  below 
the  pylorus  are  carefully  dissected  upward  so  as  to  remain  attached  to  the  pyloric 


THE  STOMACH 


395 


end  of  the  stomach  and  a  few  bleeding  points  caught  and  ligated.  The  forceps  on 
the  stomach  side  with  these  glands  is  now  lifted  sharply  iipward,  exposing  the 
gastro-duodenal  artery  in  the  groove  between  the  head  of  the  pancreas  and  the 


Fig.  452. — Showing  ligation  of  gastro-colic  and  gastro-hepatic  omentum,  leaving  all  the  lymph  nodes 
attached  to  the  part  to  be  excised.  Also  lines  of  section  of  stomach  and  duodcnmn.  The  gastric 
vessels  of  the  lesser  cur\'ature  are  clamped.     (JSlayo.) 

duodennm;  this  vessel  is  doublj^  tied  and  divided  between  ligatures.  The  glands 
in  this  region  are  dissected  upward  with  the  fat  and  hot  gauze  compresses  placed 
in  the  space. 

4.  Freeing  the  Greater  Curvature. — The  gastrocolic  omentum  is  tied  and  di- 
vided in  sections  below  the  inferior  coronary  vessels,  care  being  taken  to  avoid  the 
middle  colic  artery;  accidental  inclusion  of  this  vessel  has  caused  gangrene  of  the 
transverse  colon,  of  which  it  is  the  sole  blood  supply  in  seventy-five  per  cent  of 
the  cases  (Kronlein).  The  lymijli  nodes  lie  close  to  the  blood  vessels,  and  at  a 
point  well  beyond  these  structures  the  left  gastro-epiploic  vessel  is  caught  and  tied.' 
Care  should  be  taken  not  to  destro)'  its  branches  to  the  stomach  beyond  the  point  of 
ligation  as  it  will  be  the  sole  blood  supply  for  the  contiguous  stomach  wall. 

'  Cuneo  showed  that  no  lymph  glands  existed  to  the  left  of  the  middle  of  the  greater  curvature, 
and  that  the  circulation  in  these  was  from  left  to  right.  He  also  showed  that  the  lymphatics  of 
the  lesser  curvature  lay  in  the  wall  of  the  stomach  itself.  In  this  way  the  entire  lymph  absorbents 
of  the  pyloric  end  of  the  stomach  can  be  extirpated  en  masse. 


396 


THE  STOMACH 


5.  Removal  of  the  Diseased  Structures. — Light  elastic  holding  clamps  are  now 
placed  on  the  stomach  an  inch  or  more  back  of  the  proposed  line  of  resection,  a 
second  pair  grasping  the  tumor  side  and  the  growth  with  the  glands  and  fat  re- 
moved en  masse.     As  it  is  cut  loose,  several  catch  forceps  should  be  applied  to 


Fig.  453. — ShmvinK  aljcive  the  tcchnic  of  C.  H.  Mayo's  sero-mucous  righl^angle  suture  and  below 
Cu.sliing'.s  rigUt-augle  sero-muscular  stitch.  The  cancerous  portion  of  the  stomach  and  the  in- 
filtrated glands  have  been  removed,  together  with  the  other  two  clamps  between  which  and  those 
still  in  position  the  sections  were  made.      (Mayo.) 

the  margins  of  the  cut  stomach  surface  projecting  beyond  the  clamp  to  prevent 
retraction.  This  clamp  is  straight,  quite  elastic  and  rubber  covered  so  that  it 
will  not  crush  or  injure  the  stomach  wall.  We  have  found  those  of  Scudder  very 
satisfactory.  The  cut  gastric  wall  is  now  lightly  gone  over  with  the  actual  cau- 
tery, particularly  at  the  upper  part,  at  which  jDoint  we  are  most  liable  to  fail  to 
get  well  beyond  the  disease  (Fig.  453). 

6.  Suture  of  the  Gastric  Stump. — After  rearranging  the  hot  moist  packs,  to 
furnish  ample  protection,  with  No.  2  chromic  catgut  on  a  straight  needle,  be- 
ginning at  the  greater  curvature,  a  running  suture  is  placed  through  all  of  the 
coats  after  the  method  of  Charles  H.  Mayo.  The  needle  enters  on  the  peritonteum 
at  one  margin,  passes  through  to  the  mucous  coat,  and  directly  back  on  the  same 
side  from  mucous  coat  to  peritonseum.  By  doing  this  alternately,  first  on  one  side 
and  then  the  other,  by  a  single  suture  the  peritoneal  surfaces  are  rolled  into  con- 
tact, the  parts  being  firmly  brought  into  apposition  and  the  hasmorrhage  checked. 


THE  STOMACa 


397 


On  approacliiiig  the  lesser  curvature  it  ■«nll  usually  be  found  that  the  clamps  are 
too  close  to  the  edges  of  the  -n-ound  to  permit  of  this  manoeuvre,  and  it  may  be 
necessary  to  unclasp  them  in  suturing  the  last  inch.  As  this  situation  is  also 
under  considerable  tension,  it  is  well  to  place  one  or  two  mattress  sutures  of  linen 
at  once  at  the  upper  end  to  completely  and  permanently  secure  it,  rolling  the 
first  catgut  suture  in  by  a  wide  grasp  of  the  gastric  wall  far  enough  back  to  permit 
of  union  without  tension.  Any  point  not  well  turned  or  showing  a  tendency  to 
ooze  is  secured  by  an  independent  mattress  suture  of  linen.  Beginning  now  at  the 
greater  curvature,  a  fine  linen  continuous  Gushing  suture  turns  in  the  gastric 
wall  without  tension  over  the  first  row  (Fig.  453). 

The  duodenal  stump  is  turned  in  bj^  a  circular  suture  after  ligature  in  the 
groove  made  by  the  forceps  and  a  posterior  gastro-jejunostomy  is  performed  with- 
out a  loop,  tliat  is,  within  three  inches  of  the  origin  of  the  jejunum  (Fig.  454). 
The  opening  in  the  stomach,  however,  should  run  from  above  down,  right  to  left. 


Fig.  454. — Shomng  the  duodenum  inverted  and  closed,  the  stomach  sutured  and  the  posterior 
"no-loop"  gastro-jejunostomy  completed.     (Mayo.) 

so  that  the  proximal  end  of  the  jejunum  shall  lie  close  to  the  suture  line,  the 
distal  end  at  the  lowest  point  and  passing  to  the  left.  After  completion  of  the  gas- 
tro-jejunostomy in  the  usual  manner,  the  jejunum  at  once  drops  down  into  the 
left  iliac  fossa"  in  its  normal  position.    A  few  sutures  close  the  rent  in  the  trans- 


398  THE  STOMACH 

verse  mesocolon  in  such  fashion  as  to  protect  the  suture  line.  If  the  patient  is 
in  a  poor  condition,  an  anterior  or  posterior  MuriDhy  button  operation  can  be  made 
to  save  time.  The  button  must  be  protected,  however,  bj^  at  least  four  mattress 
sutures  of  linen  at  intervals  to  prevent  separation. 

8.  After-care. — After  resection  the  patient  should  be  placed  in  bed,  the  head 
and  shoulders  elevated  to  the  semisitting  posture,  and  a  glass  female  douche  point 
introduced  aljove  the  internal  sphincter,  through  which  from  one  to  four  c^uarts 
of  one  half  strength  normal  saline  solution  is  allowed  slowly  to  enter  the  rectum 
for  absorption  from  a  gravity  bag,  thirty  minutes  to  three  hours  being  used  in 
this  process  (MuriDhy).  This  is  repeated  in  twelve  hours  with  a  lesser  amount. 
From  one  half  to  one  ounce  of  hot  water  is  allowed  by  the  stomach  every  hour 
after  sixteen  hours,  and  the  usual  experimentation  of  licjuid  foods  Ijegun  after 
twenty-four  to  fortj'-eight  hours,  the  rectum  being  used  as  an  auxiliar}^  for  four 
or  five  days. 

Gastro-enterostomy  should  not  supplant  gastrectomy  as  a  fialliative  procedure 
unless  the  glandular  infiltration  is  too  extensive.  The  latter  operation  in  jjroper 
hands,  even  in  incuralile  cases,  will  give  a  greater  prolongation  of  life. 

Sarcoma  of  the  stomach,  either  as  a  secondary  or  primary  growth,  is  rare.  It 
has,  however,  been  observed  in  a  child  of  three  and  a  half  years  and  in  a  subject 
of  seventy^eight.  Primary  sarcoma  is  most  -infrequent,  originating  in  the  sub- 
mucosa  or  muscularis,  and  at  times  growing  to  large  size.  This  lesion  occurs  in 
the  average  at  an  earlier  period  than  cancer. 

The  diagnosis  can  only  be  made  clear  by  exploration,  and  the  indications  are 
gastrectomy,  cutting  well  away  from  the  disease,  llecovery  fi'om  the  operation 
should  be  followed  by  prolonged  injections  of  the  mixed  toxines  as  advised  by 
Coley.     (See  Sarcoma.) 

The  Duodenum. — The  'surgery  of  the  duodenum  in  its  first  portion  is  inti- 
mately associated  with  that  of  the  stomach,  while  the  second  portion  is  not  infre- 
quently involved  in  lesions  of  the  head  of  the  pancreas  and  the  common  gall  duct. 
It  is  the  most  immoval)le  part  of  the  small  intestine,  has  no  mesentery,  and  in 
its  second  portion  is  only  partially  invested  hj  peritoneum. 

Ulcer  of  the  duodenum  occurs  almost  altogether  in  the  upper  three  inches,  and 
is  frequently  associated  with  the  same  lesion  in  the  pylorus  and  pyloric  end  of 
the  stomach.  They  may  be  single  or  multiple.  The  causes  are  practically  the 
same  as  those  which  produce  gastric  ulcer.  The  diagnosis  is  more  difficult,  for 
the  reason  that  gastroscopy,  however  perfect,  has  not  yet  been  able  to  examine 
satisfactorily  the  duodenum  on  account  of  the  contractions  of  the  pylorus.  Ac- 
cording to  Graham  ^  the  most  prominent  symptom  is  pain,  which  is  felt  farther 
to  the  right  than  that  which  is  caused  by  ulcer  of  the  stomach.  It  is  generally 
sharp  and  severe,  and  comes  on  suddenly  with  a  decided  relation  to  ingestion, 
although  the  pain  and  distress  after  eating  are  felt  at  a  period  somewhat  later 
than  that  experienced  in  stomach  ulcer.  Pain  is  due  to  localized  peritonitis  or 
to  the  irritant  action  of  the  stomach  juices  on  the  aln-aded  mucous  surface.  The 
intensit}'  of  pain  is  almost  always  in  direct  ratio  to  the  degree  of  hyperacidity. 
In  thirty-two  of  forty-six  cases  reported  by  him,  vomiting  was  a  prominent  symp- 
tom. Haemorrhage  is  an  indication,  especially  when  blood  is  found  in  the  stools, 
for  in  these  forty-six  cases  bleeding  occurred  and  was  noticed  in  the  vomit  or 
the  stools  or  in  both  in  sixteen.  In  most  cases  there  will  be  a  history  of  gastric 
or  pyloric  disturlaance  for  some  weeks  or  months  preceding  the  symptoms  just 
given.  The  pain  which  is  felt  in  cholelithiasis,  although  in  practically  the  same 
area,  is  much  more  intense  and  spasmodic  in  character,  and  in  addition  is 
apt  to  be  accompanied  with  jaundice,  while  this  latter  condition  is  not  a  part 
of  ulcer  of  the  first  two  or  three  inches  of  the  duodenum.  The  only  positive 
means  of  diagnosis  is  by  exploration,  which  should  be  done  just  as  soon  as  the 
symptoms  justifj',  to  be  continued  by  excision  if  the  character  of  the  lesion  ren- 
'ders  this  necessary. 

For  the  relief  of  this  condition  a  free  incision  splitting  the  right  rectus  muscle 
near  its  middle  is  advised,  and  if  greater  space  is  needed,  A.  D.  Sevan's  lateral 
"  Christopher  Graham,  M.D.,  St.  Paul  "Medical  Journal,"  1904. 


THE  STOiL^CH  399 

curved  prolongation  of  the  incision,  either  at  the  upper  or  lower  end  or  both 
■nill  suffice.  A  transverse  division  of  the  sheath  of  the  rectus  at  any  poiat  will 
also  permit  of  a  wider  retraction  of  this  muscle.  The  technic  described  in  the 
excision  of  isolated  ulcer  of  the  stomach  will  apply  equally  well  to  ulcer  of  the 
duodenum.  It  is  important  always  in  excising  any  portion  of  the  alimentary  canal 
to  insert  the  sutures  parallel  with  the  long  axis  of  the  bowel  so  as  not  to  diminish 
its  caliber.  Slight  angulation  will  not  materially  interfere  with  the  passage  of 
ingesta.  In  case  of  perforation  an  immediate  incision,  with  closure  of  the  open- 
ing and  cleansing  of  the  infected  area,  is  imperative.  Tlie  treatment  given 
for  perforative  ulcer  of  the  stomach  is  practically  the  same  as  for  perforation  of 
duodenal  ulcer. 

Should  a  single  ulcer  be  extensive,  with  well-marked  cicatrization,  or  should 
there  be  a  number  of  ulcers  covering  an  area  too  large  for  partial  excision,  or 
should  an  ulcer  of  the  duodenum  be  continuous  through  the  pylorus,  with  a  like 
condition  of  the  stomach,  it  would  be  more  conservative  to  exsect  all  of  the  dis- 
eased bowel  and  stomach,  performing  a  direct  anastomosis  shotdd  this  be  feasible^ 
or  a  gastro-jejtmostomy,^  which  will  in  general  best  meet  the  indications. 

Perforation  of  any  point  in  the  wall  of  the  alimentary  canal  into  the  cavity 
of  the  peritonaeum  is  one  of  the  gravest  surgical  conditions.  It  is  especiallv  dan- 
gerous when  the  wall  of  the  stomach  is  involved.  The  gravity  is  in  general  pro- 
portionate to  the  size  and  location  of  the  lesion,  and  to  the  promptness  and  thor- 
oughness of  the  operative  treatment.  The  prognosis  is  always  in  a  measure 
dependent  upon  the  condition  of  the  patient's  resistance  at  the  time  of  the  accident. 

Peritonitis,  which  follows  perforating  gastric  and  duodenal  ulcer,  is  more  apt 
to  produce  an  overwhelming  septicaemia,  for  the  reason  that  the  larger  h^mphatics 
of  the  central  diaphragmatic  region  absorb  toxic  products  very  much  more  rapidly 
than  those  lower  down.  Moreover,  an  infectious  process  starting  above  naturall}' 
tends  to  spread  do^mwaTd  by  gravitation,  and  unless  cheeked  at  once,  rapidly  in- 
volves the  entire  peritoneal  cavity. 

Perforations  of  the  gall  bladder,  or  those  of  the  ileum  resulting  from  t}'phoid 
fever  or  from  other  causes  elsewhere,  will  be  considered  later. 

Gastric  and  duodenal  perforations  may  be  precipitated  by  vomiting  or  any 
extra  exertion,  or  by  overdistention  of  these  organs  with  gas  or  ingesta.  A  num- 
ber of  instances  are,  however,  recorded  in  which  the  rupture  or  perforation  took 
place  while  the  patient  was  resting  quietly  in  bed.  The  accident  is  almost  always 
preceded  by  certain  sjTaptoms  of  pain  due  to  developing  peritonitis,  and  there 
is  in  the  vast  majorit}-  of  cases  a  history  of  gastric  distress  which  may  have  given 
rise  to  a  suspicion  of  ulcer.  When  the  perforation  takes  place  and  the  contents  are 
escaping,  there  is  always  acute  and  overwhelming  pain,  which  at  the  moment  is 
felt  at  the  point  of  leakage.  Within  a  few  minutes  it  is  often  referred  to  an  area 
so  wide  that  this  symptom  is  of  little  value  as  a  guide  to  the  seat  of  perforation. 
This  is  due  to  the  fact  that  b}-  gravitation  the  extravasated  contents  are  spreading 
the  peritoneal  infection. 

It  is  exceedingly  important  that  this  condition  be  recognized  and  operated 
upon  immediately.  The  patient  should  he  placed  in  the  recumljent  posture  and 
not  permitted  to  move  until  all  necessary  preparations  are  made  for  the  adminis- 
tration of  the  ana?sthetic. 

If  taken  within  the  first  five  hours  of  perforation,  a  fairly  favorable  prognosis 
may  be  made.  After  ten  hours  it  is  exceedingly  grave.  What  is  here  said  applies 
equally  to  duodenal  as  well  as  gastric  ulcer.  The  most  careful  cleansing  should 
be  made,  and  if  there  is  any  doubt  as  to  the  thoroughness  of  the  toilet,  one  or 
more  rubber  tissue  gauze  ^riek  drains  should  be  inserted,  or  in  more  serious  cases 
a  temporary  packing  made.  The  ulcer  should  be  excised  and  the  incision  closed 
by  the  technic  alread}'  described.  " 

The  treatment  of  general  peritonitis  will  be  considered  in  another  chapter. 

'  It  must  not  be  forgotten  that  after  this  operation  there  is  no  longer  a  pyloric  muscle  to 
prevent  the  entrance  of  vmdigested  particles  into  the  intestines.  As  the  food  passes  from  the 
cesophagus  almost  directly  into  the  small  intestine,  careful  mastication  and  possiblj'  predigestion 
of  certain  articles  of  diet  are  indicated. 


CHAPTER   XXI 

THE  LIVER 

GALL    BLADDER   AND   DUCTS THE    SPLEEN",    OMENTUM,   AND   MESENTEKY 

Neoplasms. — Surgical  intervention  is  rarely  demanded  on  account  of  new 
growths  of  the  liver.  Carcinoma  is  almost  always  secondary  to  involvement  of 
the  alimentary  canal  or  mesentery,  and,  as  a  rule,  develops  slowly.  The  history 
is  that  of  progressive  emaciation  with  the  peculiar  cachexia  of  carcinoma.  It 
occurs  usually  after  the  fortieth  year  of  life,  and  when  the  tumor  develops  suf- 
ficiently to  project  helow  tlie  free  border  of  the  ribs  its  nodular  cliaracter  may  be 
appreciable  to  the  touch.  It  may  or  may  not  be  complicated  with  ascites.  The 
occurrence  of  abdominal  dropsy  points  to  the  location  of  the  cancer  near  the 
transverse  fissure  with  pressure  upon  the  portal  vein.  Widely  disseminated  metas- 
tases rarely  produce  abdominal  drops}^.  Operation  is  not  called  for  unless  it  be 
to  remove  excess  fluid  from  the  p)eritoneal  cavity. 

The  symptoms  of  ascites  are  distention  of  the  abdominal  cavity,  first  observed 
in  the  lower  portion  as 'the  patient  sits  upright  or  stands.  The  line  of  dullness 
on  percussion  ends  abruptly  from  below  upward  at  the  limit  of  the  fluid,  while 
above  this  the  note  is  immediately  tympanitic  in  character,  as  the  small  intestines 
floating  on  the  surface  of  the  fluid  are  encountered.  By  placing  one  hand  upon 
one  side  of  the  abdomen,  and  tapp)ing  with  a  finger  on  the  opposite  side,  a  wave 
or  tremor  is  imparted  to  the  liquid.  If  the  patient  be  now  pilaced  upon  the  back 
the  tympanic  resonance  will  extend  over  the  entire  front  of  the  alxlomen  from  the 
pubes  to  the  xyphoid.  These  symptoms  differentiate  ascites  from  ovarian  cysts, 
a  solid  tumor,  or  any  other  comparatively  immovable  lesion  of  the  abdominal 
cavity. 

Tapping  the  Peritoneal  Cavity  in  Ascites. — The  integument  should  be  thor- 
oughly cleansed  in  the  middle  line  half-way  between  the  umbilicus  and  the  sym- 
physis pubis,  and  the  bladder  emptied.  With  the  patient  sitting  upright,  prefer- 
ably in  a  chair,  fifteen  or  twenty  minims  of  one-per-cent  cocaine  should  be  injected 
into  and  beneath  the  skin  in  the  proposed  line  of  puncture.  A  broad  sterile 
abdominal  binder  is  applied  and  split  just  enough  to  expose  the  point  where  the 
instrument  is  to  be  introduced.  With  a  sharp  scalpel  the  skin  is  incised  for 
one  fourth  of  an  inch,  and  through  this  a  good-sized  trocar-canula  is  slowly  intro- 
duced until  resistance  ceases  as  it  is  felt  to  pass  into  the  cavity  of  the  peritonasura. 
As  the  trocar  is  withdrawn  the  fluid  immediately  escapes  through  the  eanula. 
The  most  satisfactory  eanula  should  have  an  oval  window  one  eighth  inch  from 
the  end,  as  the  omentum  or  intestine  is  apt  to  come  in  contact  with  the  open  end 
and  arrest  the  flow.  Should  the  patient  show  signs  of  syncope  the  chair  ma}'  be 
temporarily  tilted  back,  care  being  taken  to  keep  the  finger  over  the  end  of  the 
eanula  to  prevent  the  entrance  of  air.  If  the  stream  is  suddenly  stopped  by  the 
omentum  or  intestine  falling  over  the  mouth  of  the  pipette,  a  slight  movement 
of  the  instrument  may  serve  to  remove  the  obstruction,  or  it  may  be  necessary  to 
introduce  a  sterile  prol^e  through  the  eanula  in  order  to  clear  it.  As  soon  as  the 
stream  begins  to  break  up  into  drops,  showing  that  the  fluid  above  the  level  of 
the  perforation  has  escaped,  the  abdominal  binder  should  be  dra^oi  tighter  imtil 
the  flow  ceases.  The  eanula  shoidd  he  removed  and  the  opening  immediately 
covered  with  sterile  gauze  held  in  place  by  adhesive  strips  and  a  binder  around 
the  abdomen. 

400 


THE  LHER  40l 

Sarcoma  of  the  liver  is  eveii  rarer  than  cancer.  This  neoplasm  may  be  located 
in  the  gastrohepatic  omentiim,  and  involve  the  liver  by  extension.  This  occurred 
in  a  ver}'  remarkable  case  operated  upon  by  the  author.  Five  gallons  of  fluid  by 
measurement  were  removed  by  tapping  the  aljdomen  as  just  described.  The  mass, 
as  large  as  the  head  of  an  infant,  could  be  distinctly  felt,  attached  to  the  lower 
border  of  the  left  lobe  of  the  liver  and  extending  five  or  six  inches  along  the 
gastrohepatic  omentum  in  the  direction  of  the  stomach.  Under  complete  nar- 
cosis a  free  exploratory  incision  was  made  over  the  most  prominent  portion.  The 
tumor  was  of  reddish-brown  color,  hard  and  ver}^  vascular.  Xo  attempt  was  made 
at  removal.  The  wound  was  treated  by  the  open  method  and  packed  with  sterile 
gauze  in  order  to  secure  adhesions  between  the  peritona?uni  and  the  surface  of 
the  neoplasm  for  the  purpose  of  streptococcus  inoculation.  Seventy-two  hours 
later  the  packing  was  removed  and  infection  of  the  mass  was  secured  by  changing 
the  dressings  without  aseptic  precautions.  The  tissues  about  the  wound  became 
red  and  inflamed,  but  the  suppuration  was  not  profuse.  Under  this  novel  treat- 
ment the  tumor  diminished  gradually  in  size,  pressure  on  the  portal  vein  ceased, 
and  the  ascites  did  not  return.  Ten  years  have  elapsed  since  the  operation,  and 
the  patient  is  now  (1907)  in  excellent  health  and  actively  engaged  in  large  busi- 
ness enterprises. 

Hydatid  Ci/sts. — Cystic  tumors  caused  by  the  presence  of  the  larva  of  the 
tapeworm  {echinococcus  hominis)  are  met  with  in  the  liver  more  frequently  than 
in  any  other  part  of  the  body.  They  may  be  multiple  or  single,  and  maj^  grow 
so  large  that  they  break  through  the  diaphragm,  emptjing  their  contents  into  the 
pleural  cavity  or  lung,  or,  extending  downward,  may  occupy  a  large  part  of  the 
abdomen.     They  occasionally  open  into  the  stomach  or  other  hollow  viscus. 

The  differentiation  of  hydatids  from  abscess  of  the  liver  is  not  difficult.  In 
the  former  there  is  no  tenderness  nor  any  symptoms  of  sepsis. 

In  h}-perdistention  of  the  gall  bladder  there  is  pain,  and  jaundice  is  apt  to 
exist.  Aspiration  with  a  delicate  needle  will  make  the  diagnosis  positive.  Hydatid 
cysts  contain  a  water}'  fluid,  clear  or  of  light-straw  color,  and  in  some  instances 
fragments  of  the  liooklds  may  be  discovered. 

Treatment. — The  contents  should  be  drawn  off  with  the  aspirator,  and  the 
procedure  repeated  as  often  as  necessary.  A  single  operation  may  effect  a  cure. 
The  needle  should  be  introduced  at  the  most  superficial  portion  of  the  tumor.  As 
the  fluid  ceases  to  flow  the  canula  should  be  withdrawn  and  the  opening  stopped 
by  gauze  held  in  place  b}-  adhesive  strips.  Local  anjesthesia  will  suffice  in  this 
operation.  Complete  rest  in  the  recumbent  posture  should  be  enforced  for  at 
least  a  week  after  the  operation.  In  the  event  of  sepsis,  incision  and  drainage  are 
imperative.  Should  repeated  aspirations  fail  to  efEect  a  cure,  a  drainage-tube 
should  l)e  inserted,  as  advised  by  Yerneuil,  after  adhesions  have  been  secured. 

Hepatic  Abscess.- — A  circumscribed  collection  of  ptis  in  the  liver  is  compara- 
tively rare.  It  occurs  more  frequently  in  tropical  or  semitropical  countries  on 
accoimt  of  the  greater  frequency  there  of  intestinal  diseases.  Any  infectious 
process  in  the  alimentary  canal  may  produce  hepatic  abscess  from  pyogenic  organ- 
isms carried  into  the  radicles  of  the  portal  vein.  Appendicitis  may  cause  sup- 
puration in  this  organ  either  by  direct  extension  or  through  the  portal  system. 
These  metastases  are  generally  multiple.  Direct  infection  through  a  penetrating 
wound  may  also  cause  abscess  of  the  liver.  In  exceptional  cases  ingested  substances, 
such  as  bone,  etc.,  have  been  known  to  pass  from  the  alimentary  canal  into  the 
substance  of  this  organ,  producing  fatal  pyogenic  infection. 

Abscess  (subphrenic)  located  upon  the  upper  surface  of  the  liver  occurs  in  a 
certain  proportion  of  cases  as  the  result  of  gastric  or  duodenal  ulcer. 

Symptoms  and  Diagnosis. — The  early  recognition  of  hepatic  abscess  is  difficult. 
Pain  is  not  a  prominent  symptom.  Exacerbations  of  fever,  with  chills  or  rigors, 
are  apt  to  occur,  and  there  follows  a  gradual  impairment  of  health.  Jaundice 
is  not  present  unless  the  collection  of  pus  is  near  the  transverse  fissure,  where  it 
may  partially  or  completely  occlude  the  hepatic  duct. 

Empyema  of  the  pleura  or  of  the  gall  bladder  or  subphrenic  abscess  may  he 
mistaken  for  abscess  of  the  liver.     In  pleural  empyema,  where  •  encapsulation  does 


402  THE  LIVER 

not  exist,  a  change  of  posture  will  change  the  percussion  sounds.  An  overdis- 
tended  gall 'bladder  may  be  eliminated  by  bearing  in  mind  its  location  in  front 
and  low  down  where  abscess  is  extremely  rare,  and  also  from  the  fact  that  a 
distended  gall  bladder  may  be  moved  independently  of  the  liver. 

The  differentiation  from  hydatid  cyst  has  just  been  given.  Should  the  in- 
fected area  be  near  the  upper  surface  and  free  border  of  the  liver,  deep  palpation 
may  develop  soreness.  As  a  last  resort  the  exploring  needle  will  positively  deter- 
mine a  diagnosis,  but  this  should  not  be  used  until  everything  is  ready  for  imme- 
diate operation. 

The  prognosis  is  unfavorable.  Left  alone,  a  fatal  termination  is  almost  in- 
evitable, either  from  rupture  into  the  peritonasum  or  pleura  or  from  prolonged 
septicemia. 

Treatment. — Evacuation  is  the  only  rational  treatment.  An  effort  should  be 
made  to  locate  the  most  superficial  portion  of  the  abscess.  At  this  point  the 
aspirator  needle  should  be  passed  through  the  most  convenient  intercostal  space 
into  the  substance  of  the  liver,  in  the  supposed  direction  of  the  pus  cavity.  As 
soon  as  by  withdrawing  the  piston  pus  appears  in  the  barrel  of  the  syringe,  this 
should  be  unscrewed  and  the  needle  left  in  situ.  Enough  pus  should  be  with- 
drawn to  relieve  tension.  An  incision  about  four  inches  long  parallel  with  and 
over  the  center  of  the  nearest  rib  is  made,  the  center  of  the  cut  being  near  the 
needle.  A  subperiosteal  exsection  of  three  inches  of  the  rib  should  be  made  and 
the  costal  pleura  incised  for  two  inches.  The  edges  of  the  incision  in  the  costal 
pleura  are  carefully  sutured  with  a  chromicized  catgut  continuous  suture  to  the 
reflection  of  the  pleura  which  covers  the  diaphragm,  forming  a  buttonhole,  in 
the  center  of  which  is  the  needle.  This  may  now  be  withdrawn,  a  slight  punc- 
ture with  the  scalpel  point  made  in  the  diaphragm,  and  a  dressing  forceps  carried 
through  this  into  the  abscess  cavity.  By  careful  separation  of  the  handles  of 
this  instrument  the  opening  will  be  sufficiently  enlarged  to  give  a  free  discharge 
of  pus.  A  single  or  double  drainage-tube  should  now  be  inserted.  If  irrigation 
is  done,  normal  salt  solution  shoidd  be  used  and  great  care  taken  not  to  over- 
distend  the  cavity.  By  this  operation  infection  of  the  pleural  cavity  is  avoided, 
while  the  peritoneal  cavity  is  not  opiened. 

Subpkrenic  abscess  situated  above  the  liver  at  any  point  may  be  evacuated  by 
this  procedure. 

Displacement. — As  the  result  of  accident,  or  at  times  from  tight  lacing,  the 
liver  is  occasionally  displaced  downward.  A  properly  adjusted  compress  and 
support  must  be  relied  upon  to  hold  the  organ  near  its  normal  position.  In  a 
single  instance  which  came  under  the  observation  of  the  author,  this  organ  was 
sutured  in  position  with  a  very  satisfactory  result  by  practically  the  same  method 
as  advised  in  the  cure  of  floating  kidney.  The  patient  was  kept  in  bed  in  a 
modified  Trendelenburg  posture  for  a  number  of  weeks  in  order  to  secure  firm 
adhesions.  The  same  method  of  securing  adhesions  between  the  upper  surface  of 
the  liver  and  the  diaphragm  in  establishing  a  collateral  portal  circulation  in 
cirrhosis  may  be  practiced  in  anchoring  this  organ. 

Gunshot  or  other  penetrating  wounds  of  the  liver  may  demand  operation  for 
the  arrest  of  haemorrhage  as  well  as  for  drainage  in  sepsis.  A  number  of  in- 
stances are  on  record  where  free  incision  into  the  peritoneal  cavity  has  been  made 
and  hsemorrhage  arrested  by  packing  the  -wound  in  the  liver  with  sterile  gauze, 
and  walling  off  the  general  peritoneal  cavity  until  protecting  adhesions  were  se- 
cured. For  the  arrest  of  haemorrhage  here  blood  pressure  should  be  lowered  at 
once  by  Detmold's  method  of  constriction  of  the  thighs  and  arms.  The  author 
has  successfully  controlled  severe  hemorrhage  from  the  liver  by  suturing  a  cut 
or  abraded  surface,  and  by  uniting  the  torn  edges  with  catgut. 

Operation  for  the  Relief  of  Ascites. — In  cirrhosis,  when  the  portal  circulation 
is  hopelessly  obstructed,  the  following  operation  is  advised  in  the  effort  to  estab- 
lish a  collateral  venous  route.  The  fluid  should  be  removed  by  tapping,  from 
twelve  to  twenty-four  hours  before  the  operation.  A  free  incision  in  the  middle 
line  is  made,  commencing  at  the  ensiform  cartilage  and  extending  to  the  umbili- 
cus, and,  if  necessary,  half-way  between  that  point   and  the  pubis.     Any   fluid 


THE  GALL  BLADDER  .  403 

found  in  the  cavity  should  be  removed  by  mopping.  The  peritoneum  lining  the 
abdominal  wall  and  diaphragm  should  be  irritated  by  friction  with  a  coarse  crash 
laparotomy  pad  or  swab,  and  the  upper  surface  of  the  liver  scraped  with  a  scalpel 
or  teased  with  needles.  The  entire  surface  of  the  omentum  and  any  mesentery, 
the  circulation  of  which  may  be  utilized  by  adhesions  with  the  abdominal  wall, 
should  be  also  irritated  by  friction.  The  round  ligament  of  the  liver  should  be 
shortened  by  suturing  it  in  folds  and  attaching  it  to  the  parietal  peritonteum  and 
the  rectus  muscle  by  as  many  ehromicized  catgut  sutures  as  may  be  required.  The 
anterior  edge  of  the  liver  should  also  be  sutured  to  the  parietal  peritona?um,  and  the 
operation  completed  by  passing  a  number  of  stitches  through  the  omentum,  attach- 
ing this  in  a  transverse  direction  to  the  parietal  peritonaBimi  by  several  parallel  rows 
of  sutures.  On  account  of  the  low  resistance  of  these  subjects  the  operation  should 
be  completed  as  rapidly  as  possible  with  the  minimum  of  the  anassthetic,  relying 
in  large  measure  upon  morphia  and  nitrous  oxide  gas.  It  is  well  to  practice  ex- 
traordinary care  in  asepsis.  The  success  of  the  operation  will  be  determined  Ijy  the 
extent  and  thoroughness  of  the  adhesions  of  the  opposing  surfaces  and  the  new 
formation  of  blood  vessels  which  will  carry  the  circulation  from  the  radicles  of 
the  portal  vein  to  the  heart  by  way  of  the  veins  of  the  diaphragm  and  the  abdomi- 
nal wall. 

The  Gall  Bladder  and  Gall  Ducts. — Cliolecystotomy  is  indicated  for  the  re- 
moval of  stones  from  the  gall  bladder  and  to  secure  drainage  in  empyema  under 
conditions  which  contra-indicate  the  removal  of  this  organ. 

While  pain  is  a  frequent  symptom  of  stone  it  is  not  so  prominent  as  when 
these  concretions  are  lodged  in  the  cj'stic  or  common  duct.  In  common  duct  ob- 
structions jaundice  is  a  prominent  symptom,  and  although  it  maj^  occur  in  those 
cases  of  calculus  in  the  gall  bladder  which  by  reason  of  their  size,  weight,  or 
location  partially  or  completely  obstruct  the  hepatic  duct,  under  other  conditions 
the  gall  l:)ladder  may  contain  a  large  numljer  of  stones  -without  icterus.  It  is 
also  true  that  biliary  calculi  may  remain  for  years  without  attracting  the  atten- 
tion of  the  patient  or  surgeon  as  far  as  pain  is  concerned,  and  unless  infection 
with  symptoms  of  septicaemia  result  they  may  entirely  escape  notice. 

In  addition  to  the  symptoms  just  given,  the  diagnosis  may  be  facilitated  by 
local  tenderness,  or  in  hyperdistention  by  the  presence  of  a  tumor  just  below 
the  free  border  of  the  liver  in  a  direct  line,  usually  between  the  right  nipple  and 
the  umbilicus.  The  presence  of  hydatids  may  also  produce  tumefaction,  but  the 
absence  of  pain,  jaundice,  and  any  suggestion  of  infection  will  exclude  the  echino- 
coccus  cyst. 

Treatment. — Opening  the  gall  bladder  under  ordinary  conditions  is  not  a  very 
difficult  or  dangerous  procedure.  It  only  becomes  serious  when  the  patient  is 
exhausted  by  long-continued  sepsis,  pain,  and  starvation. 

In  all  operative  procedures  upon  the  gall  bladder  and  ducts  the  incision 
is  that  given  in  describing  the  operation  of  cholecystectomy,  but  for  the  removal 
of  stones  or  simply  estaljlishing  temporary  drainage  for  empyema,  a  much  smaller 
opening  will  suffice.  This  smaller  opening  should,  however,  be  in  the  line  of  the 
larger  incision,  so  that  should  the  necessity  for  a  major  procedure  arise  it  can 
be  extended  in  both  directions  until  sufficient  room  is  secured.  The  center  of  this 
primary  incision  should  be  over  the  gall  bladder,  and  should  split  the  right  rectus 
muscle  in  this  location.  If  the  gall  bladder  is  enlarged  and  has  Ijeen  subjected  to 
repeated  infection,  in  many  instances  adhesions  will  have  occurred  between  its 
peritoneal  covering  and  that  of  the  abdominal  wall,  so  that  in  cutting  do-wn  at 
this  location  the  summit  of  the  gall  bladder  will  be  encountered  and  may  be 
entered  without  opening  into  the  general  peritoneal  cavity.  When  this  condition 
is  present  immediate  incision  may  be  made,  and  two  loop  sutures  passed  from 
\^ithin  the  gall  bladder  outward  "through  the  abdominal  wall  on  either  side  of 
the  opening,"to  be  tied  long  and  used  to  support  the  bladder  and  prevent  its  being 
torn  loose  during  any  necessary  manipulation.  In  removing  calculi  from  the 
gall  bladder  a  dull  scoop  may  be  employed,  or  a  small  Blake  forceps,  which  should 
be  made  of  light,  springy  steel  and  fenestrated  so  that  the  stones  may  be  readily 
caught  and  not  crushed  by  overpressure.     Another  useful  method,  especially  for 


404 


THE  GAI.L  BLADDER 


dislodging  small  calculi  wliicli  are  more  or  less  impacted  in  the  deeper  portions 
of  the  gall  bladder  and  in  the  cystic  duct,  is  to  attach  a  fairly  stiff  rubber  tube 
to  an  ordinary  syringe,  distend  the  gall  bladder  by  throwing  in  a  sufficient  quan- 
tity of  hot  salt  solution,  and  immediately  drawing  it  back  into  the  syringe  by 
suction.  In  this  way  small  calculi  in  the  deeper  portions  of  the  neck  of  the  gall 
bladder  may  be  removed.  A  very  careful  search  should  be  instituted  for  concre- 
tions which  are  frequently  lodged  in  the  valvelike  pockets  at  the  junction  of  the 
cystic  duct  with  the  bladder.  These  will  require  a  dull  fenestrated  curette,  or 
scoop  for  their  dislodgment.  When  this  latter  condition  exists,  the  complete 
removal  of  the  gall  bladder  will  in  general  be  a  more  satisfactory  procedure. 

When  drainage  is  necessary,  and  when  there  are  no  firm  adhesions  between 
the  summit  of  the  gall  bladder  and  the  peritona?uni  of  the  alxlominal  wall,  and  in 
all  cases  where  this  organ  cannot  be  brought  into  the  opening  of  the  rectus,  the 
following  operation  is  advised : 

A  drainage-tube  of  soft  rubber,  with  a  diameter  of  about  one  quarter  of  an  inch 
and  of  sufficient  length  to  extend  from  near  the  neck  of  the  gall  bladder,  well  out 
through  the  abdominal  incision,  is  fenestrated  (fish-tail)  on  opposite  sides  one 
fourth  of  an  inch  from  the  inner  end.  It  should  be  wrapped  or  wound  with  two 
or  three  layers  of  absorbent  gauze,  and  over  this  one  or  two  layers  of  rubber-tissue 
protective. 

The  abdominal  incision  having  been  sufficiently  enlarged,  the  summit  of  the 
gall  bladder  is,  if  possible,  brought  into  and  partially  through  the  wound.  If  it  is 
too  short  to  protrude,  it  should  be  brought  up  as  near  the  incision  in  the  abdominal 
peritonaeum  as  possible. 

A  purse-string  suture  of  ISTo.  2  chromicized  catgut  is  inserted  with  a  half-curve 
needle  completely  around  that  portion  of  the  summit  of  the  gall  bladder  (about  one 
inch  in  diameter)  through- which  the  drainage  incision  is  to  be  made.  Gauze  mats 
or  a  gauze  pack  should  be  carefully  inserted  to  prevent  any  possible  leakage  into 
the  peritoneal  cavity.  If  the  gall  bladder  is  hyperdistendcd,  it  is  advisable  to  intro- 
duce an  aspirator  and  draw  off  a  jDortion  of  the  fluid  in  order  to  prevent  overflow. 
The  incision  into  the  gall  bladder  is  now  made  within  the  circumference  of  this 
first  purse-string  suture.  As  the  bladder  is  firmly  held  by  forceps  its  liquid  con- 
tents may  be  removed  by  wisps  of  absorbent  gauze  on  forceps.  A  search  should  be 
instituted  for  calculi,  and  any  present  should  be  re- 
moved. The  drain age-tulje  should  next  l)e  carried  in 
to  a  depth  of  three  fourths  of  an  inch  and  the  purse- 
string  suture  snugly  tied,  the  peritoneal  surfaces  of 
the  gall  bladder  being  enfolded  and  brought  into  eon- 
tact,  as  they  grasp  the  tube,  where  the  fenestras  have 
been  made.  The  sutures  should  be  tied  tight  enough 
to  hold  snugly,  but  not  sufficiently  tight  to  diminish 
the  caliber  of  the  tube. 

The  tube  should  be  pushed  in  deeper,  invaginating 
the  gall  bladder  for  one  half  or  three  quarters  of  an 
inch  (see  Fig.  455).  A  second  purse-string  suture  of 
ISTo.  2  ten-day  chromic-acid  catgut  is  introduced  at  this 
level,  taking  great  care  that  the  point  of  the  needle 
does  not  penetrate  the  cavity  of  the  gall  bladder.  This 
purse  string  is  tied  snugly  about  the  tube,  and  in 
this  way  leakage  into  the  peritoneal  cavity  is  practi- 
cally impossible.  By  attaching  a  longer  piece  of  rub- 
her  tubing,  all  the  drainage  may  be  carried  away  from 
the  dressing  into  a  receptacle  properly  adjusted. 

Within  a  week  or  ten  days  firm  adhesions  will  have 
formed,  which  will  prevent  leakage  when  the  drainage- 
tube  is  removed.  Drainage  should  be  continued  as 
long  as  any  suppuration  is  present.  After  the  tube  is  removed,  the  discharge  will 
usually  continue  for  several  days  or  weeks  before  final  closure. 

If  for  any  reason  this  procedure  may  not  be  carried  out  and  the  summit  of  the 


Fig.  455.  —  Rockey's  valvular 
method  of  closing  the  gall 
bladder  for  drainage.  (Mur- 
phy's General  Surgery,  1906.) 


THE   GALL   BLADDER  405 

gall  bladder  can  be  brought  into  the  wound,  it  should  be  held  there  while  sutures 
of  fine  black  linen  (No.  50)  or  silk  are  inserted  in  such  a  way  as  to  stitch  the 
peritonasum  lining  the  edges  of  the  abdominal  wall  to  that  covering  the  gall  bladder, 
taking  care  not  to  permit  the  needle  to  pass  into  the  cavity  of  this  organ. 

An  interrupted  suture  with  an  interval  of  about  three  sixteenths  of  an  inch  is 
preferable,  and  one  end  should  be  left  two  inches  long  to  facilitate  removal  by 
traction  after  adhesions  have  taken  place.  If  the  necessity  for  drainage  is  not 
urgent,  the  wound  should  be  left  open  and  packed  for  twenty-four  or,  preferably, 
forty-eight  hours,  when  adhesions  will  have  formed  and  the  gall  bladder  may  be 
incised.  For  this  secondary  incision  cocaine  anesthesia  will  suffice.  It  is  a  wise 
precaution,  when  the  operation  of  stitching  the  gall  bladder  to  the  margins  of  the 
peritoneal  incision  is  completed,  to  insert  two  long  loop  sutures  into  the  summit 
of  this  organ  on  opposite  sides  of  the  wound.  These  sutures  will  serve  as  a  guide 
to  the  incision  which  is  later  to  be  made. 

In  this  operation  drainage  is  secured  by  the  use  of  one  or  two  pieces  of  plain 
soft-rubber  tubing,  which  should  be  allowed  to  remain  until  all  inflammation  has 
subsided. 

Cholecystectomy. — Complete  removal  of  the  gall  bladder  is  destined  to  take 
the  place  of  many  operations  for  drainage  which  have  heretofore  been  preferred. 
Infection  through  the  communication  of  this  organ  with  the  alimentary  canal  is 
of  frequent  occurrence,  and  when  as  a  result  of  the  presence  of  calculi  or  repeated 
temporary  or  the  j^ermanent  obstruction  of  the  common  or  cystic  duct  this  condi- 
tion becomes  a  danger  to  the  welfare  of  the  individual,  extirpation  rather  than 
drainage  of  the  gall  bladder  should  be  done  if  the  resistance  of  the  patient  will 
justify  the  procedure.  If  not,  drainage  may  restore  the  normal  resistance,  and  later 
cholecystectomy  done.  According  to  AV.  J.  Mayo,  "a  gall  bladder  once  infected 
remains  infected,  needing  only  a  disturbing  element  to  produce  its  original  in- 
tensity." 

Operation. — If  cholecystectomy  is  found  necessary  after  the  incision  which  has 
just  been  advised  for  purposes  of  drainage,  this  should  be  enlarged  by  splitting  the 
rectus  as  may  be  required  to  give  ample  room,  but  in  general,  in  all  operations 
upon  the  deeper  portions  of  the  gall  bladder  and  the  bile  ducts,  Eobson's  technic, 
as  employed  at  the  Mayo  clinic  and  as  modified  by  A.  D.  Bevan,  should  be  pre- 
ferred. A  sand-bag  is  placed  under  the  patient's  back  in  order  to  increase  the 
forward  convexity,  lift  the  arches  of  the  ribs,  and  aid  in  carrying  the  liver  and 
diaphragm  as  far  out  of  the  way  as  possible.  A  longitudinal  incision  is  made 
through  the  right  rectus  muscle,  with  division  of  its  inner  half  parallel  with  the 
costararch  as  far  as  the  ensiform  cartilage,  when  necessary  (Bevan).  When  a 
larger  space  becomes  absolutely  necessary  (and  unless  an  operator  is  more  than 
ordinarily  expert  a  free  exposure  is  essential),  a  transverse  division  of  the  sheath 
of  the  outer  half  of  the  rectus  will  permit  a  wider  retraction.  With  proper  retrac- 
tion, and  elevation  of  the  left  lobe  of  the  liver,  together  with  the  costal  arches, 
the  gall  bladder  is  clearly  iu  view.  The  cystic  duct  and  vessels  should  be  made  out 
and  clamped  with  a  single  forceps  (Fig.  456),  while  a  second  curved  forceps  of 
sufficient  grasp  closes  the  apex  of  the  gall  bladder  and  prevents  leakage  as  the  duct 
and  vessels  are  divided  between  the  two  clamps.  Before  this  division  is  made  it  is 
a  wise  precaution  to  insert  a  gauze  mat  underneath  to  prevent  peritoneal  soiling.^ 
The  gall  bladder  is  now  easily  dissected  from  below  upward,  and  removed.  The 
artery  having  been  first  secured,  the  bleeding  is  insignificant.  A  chromicized  catgut 
ligature  should  be  placed  laeyond  the  remaining  forceps,  tying  duct  and  vessels  with 
this  single  ligature.  The  stump  of  the  cystic  duct  should  be  disinfected  thoroughly 
with  carbolic  acid,  carried  on  a  wisp  of  cotton  attached  to  the  end  of  a  delicate 
probe  or  holder.  This  is  introduced  into  the  funnel-shaped  end  and  moved  around 
until  the  acid  has  been  brought  thoroughly  in  contact  with  the  inner  surface.    A 

•  So  many  cases  are  being  constantly  recorded  where  by  oversight  materials  used  in  intra^ 
abdominal  operations  have  been  left  in  situ  after  closure  of  the  wound,  that  in  no  case  should  a 
mat  or  sponge  be  introduced  without  a  tape  or  thread  connected  -nith  it,  which  shall  remain  outside 
and  have  a  forceps  attached  to  it.  It  would  be  better  when  possible  to  use  long  rollers  of  gauze 
of  suitable  width  so  that  a  portion  of  it  should  of  necessity  remain  without. 


406 


THE   GALL   BLADDER 


drop  or  two  of  alcohol  may  be  added  to  neutralize  any  excess  of  the  acid.  The 
edges  of  the  peritonfeiim  on  either  side  of  the  raw  surface  of  the  liver  from  which 
the  gall  bladder  has  been  removed  shoidd  be  brought  together  by  catgut  sutures  in 
order  to  prevent  adhesions   (Fig.  457). 


Fig.  4.56. — Cholecystectomy,  showing  clamps  applied  to  cystic  duct  and  cystic  vessels.     (After  Mayo.) 


A  light  cigarette  drain  shoidd  be  allowed  to  remain  in  place  for  two  or  three 
days,  the  deeper  end  of  which  should  be  held  in  place  by  a  small  plain  catgut  suture 
which  attaches  it  to  the  point  where  the  duct  has  been  tied. 

These  drains  play  an  important  role  in  the  sitrgery  of  the  bile  duets.  They  are 
made  of  a  loose  wick  or  light  roll  of  absorbent  gauze  wrapped,  in  cigarette  fashion, 
in  one  or  two  layers  of  rubber-tissue  protective,  loosely  rolled.  No  threads  should 
be  tied  about  them. 

When  well-marked  infection  is  present,  a  larger  drain  may  be  required.  They 
are  made  of  soft-rubber  tubing  split  spirally  from  one  end  to  the  other,  inside  of 
which  is  placed  a  loose  wick  of  absorbent  gauze,  while  around  the  tube  are  one  or 
two  layers  of  absorbent  gauze,  and  over  this  a  layer  or  two  of  rubber-tissue  pro- 


THE   GALL   DUCTS 


407 


teetive.  A  drain  should  be  long  enough  to  project  two  or  three  inches  from  the 
abdomen,  and  in  order  to  hold  it  accurately  in  place  the  lower  end  should  be  fast- 
ened by  a  plain  catgut  suture  to  the  point  from  which  drainage  is  desired. 

Choledochotomy. — Operations  upon  the  bile  ducts  are  usually  performed  on 
account  of  the  presence  of  gallstones,  which  may  partially  or  completely  occlude 
the  common  duct,  and  less  frequently  the  cystic  and  hepatic  ducts.  At  times  a 
puttvlike  mass  of  decomposing  bile  salts  and  other  waste  material  fills  the  common 
and  hepatic  duct  well  back  into  the  substance  of  the  liver.  The  author  has  met 
with  two  instances  of  this  land,  in  both  of  which  there  was  an  extraordinary 
condition  of  cholasmia,  and  in  one  of  which  he  was  enabled  to  empty  the  gall  ducts 
by  milking  this  soft  material  into  the  duodenum. 

Intrahepatic  Cholelithiasis. — The  presence  of  gallstones  in  the  branches  of  the 
hepatic  diict  within  the  liver  is  not  altogether  infrequent.^  Of  these  reported,  a 
large  proportion  doubtless  formed  in  the  small  ducts  within  the  substance  of  the 
liver. 

The  more  consistent  symptoms  of  stone  in  the  common  or  hepatic  duct  is  jaiin- 
dice  and  pain.     There  may,  however,  be  numerous  calculi  in  these  tubes  without 


Fig.  457. — Cholecystectomy,  showing  cj'stic  duct  and  vessels  ligated.     Gall  bladder  partially  separated 
and  sutures  in  position  to  cover  the  exposed  liver  substance.      (After  Slayo.) 


producing  jaundice,  and  in  rare  instances  without  causing  sufficient  pain  to  attract 
the  attention  of  the  surgeon  directly  to  this  locality.  Small  calculi  which  are  pro- 
ducing symptoms  of  sepsis  may  even  escape  notice  when  the  duct  is  laid  open  in 
the  course  of  a  surgical  procedure.  The  Mayo  technic  of  this  operation  is  as 
follows :  - 

If  the  common  duct  contains  stone,  one  is  seized  between  the  left  forefinger 

1  Dr.  Edwin  Bier,  of  New  York.  Report  from  the  Laboratory  of  Professor  Weichselbaum, 
"Vienna  Medical  News,"  July  30.  1904. 

'  "New  York  Medical  Record,"  April  30,  1904. 


408 


THE  GALL  DUCTS 


and  thumbs  and,  using  the  stone  as  a  guide  (Elliot),  two  lateral  mattress  sutures 
are  placed,  leaving  a  free  space  between  for  longitudinal  incision  of  the  duct  in 
its  visible  portion  between  the  cystic  duct  entrance  and  the  duodenum.  These  two 
threads  with  long  ends  act  as  tractors,  and  after  removal  of  stones  may  be  crossed 
to  unite  the  duct  margins,  always  leaving  a  little  chance  for  drainage  at  the  ends 
of  the  incision   (Fig.  458).     In  the  majority  of  cases,  unless  the  cystic  duct  is 


Fig.  4.5S. — Choledochotomy,  showing  method  of  placing  working  sutures  in  common  duct.    (After  Mayo.) 

freely  open  for  drainage  through  a  eholecystostomy,  it  is  better  practice  to  leave 
the  incision  open,  either  completely  or  in  part,  and  use  the  threads  to  fasten  the 
drains  in  position.  Fixing  the  drains  prevents  floating  by  biliary  escape  or  derange- 
ment by  diaphragmatic  action  exerted  upon  the  liver.  The  gauze  is  surrounded 
on  its  inner  and  lower  surface  by  rubber  tissue  to  prevent  peritoneal  adhesions. 

In  se]3tic  cases  a  rubber  tube  one  quarter  to  one  third  inch  in  diameter  is  cut 
fish-tailed  and  introduced  into  the  dilated  duct,  and  with  a  needle  the  tube  is  secured 
in  position  by  the  original  catgut  thread  on  each  side.  The  outer  end  of  the  tube 
can  be  placed  in  a  flattened  flask,  which  is  held  in  the  dressing.  A  light  gauze 
pack  is  placed  about  the  tube  and  fastened  with  the  same  thread.  The  notch  cut 
in  each  side  of  the  deep  end  of  the  tube  permits  bile  to  pass  on  and  out  through 
the  papilla  at  any  time,  and  yet  furnishes  just  as  complete  drainage. 

In  removing  stones  from  the  common  duct  the  finger  is  the  only  reliable  guide, 
and  without  it  one  cannot  be  sure  that  no  calculi  have  been  missed,     The  bile 


THE  GALL  DUCTS  409 

pressure  will  cause  an  ohstnicted  common  duct  to  distend  to  a  size  sufficient  to 
admit  a  medium  forefinger  of  the  left  hand. 

Calculi  in  the  common  duct  are  often  so  well  concealed  that  they  may  even 
escape  detection  by  the  sense  of  touch.  Where  all  the  symptoms  are  present  and 
where  the  duct  is  dilated  and  Jaundice  is  present,  having  exposed  this  area  and 
finding  no  adequate  cause  for  the  conditions  which  exist,  the  duct  should  be  laid 
open  and  thoroughly  exjilored.  As  to  the  danger  of  hemorrhage  from  the  portal 
vein  and  hepatic  artery.  Mayo  asserts  that  in  a  well-conducted  operation  for  com- 
mon duct  stones  these  structures  are  not  seen. 

"  The  cystic  artery  frequently  comes  ofl:  from  the  superior  pancreato-duodenal 
(Brewer),  and  if  cut  bleeds  sliarply,  and  a  large  vein  may  cross  the  duct,  and  if 
wounded  will  cause  the  field  to  fill  with  blood,  leading  to  erroneous  belief  as  to 
origin.     These  vessels  are  easily  caught  and  tied. 

"  It  sometimes  happens  that  no  stone  can  be  felt,  yet  from  the  symptoms  we 
are  morally  certain  they  are  in  the  common  duct,  while  the  parts  are  adherent,  with 
the  anatomy  so  disturbed  that  nothing,  not  even  the  duct  itself,  can  be  recognized. 
To  find  and  open  the  common  duct  in  such  cases,  split  the  gall  bladder  from  top 
to  bottom  and  extend  the  incision  the  entire  length  of  the  cystic  duct,  and  from 
this  point  into  the  common  duct.  The  adhesions  are  left  intact  to  act  as  barriers 
to  infection.  After  completing  the  common-duct  work,  the  cystic  duct  is  cut 
across  near  the  common  duct  and  the  gall  bladder  removed  from  below  upward,  or, 
in  some  cases  (where  the  adhesions  render  it  necessary),^  the  mucous  membrane 
may  be  entirely  peeled  off." 

'  The  reparative  power  of  the  common  duct  is  not  exceeded  by  any  mucous  lined  channel  in 
the  human  body.  One  not  infrequently  encounters  cases  in  which  this  channel  after  operation 
looks  very  badly  with  widely  separated  and  ragged  walls,  and  one  fears  that  union  will  not  take 
place,  yet  healing  almost  invariably  occurs,  whether  the  duct  is  sutured  or  not.  During  1904  the 
following  three  cases,  illustrating  the  reparative  power  of  the  common  duct,  occurred  in  St.  Mary's 
Hospital.  The  first,  a  female  patient,  age  twenty-two,  with  acute  infectious  cholecystitis  and 
cholangitis,  with  stones  in  gall  bladder.  In  emptying  the  gall  bladder  much  puttylike  material 
was  forced  into  the  deep  ducts.  To  enable  removal  of  this  substance  and  proper  drainage,  it  was 
necessary  to  split  the  hepatic  and  common  ducts  from  the  liver  to  the  shelter  of  the  duodenum; 
the  gall  bladder  was  also  removed.  The  margins  of  the  common  duct  were  approximated  in  three 
places  by  catgut  sutures,  the  balance  being  left  open  for  drainage.  Patient  left  the  hospital  in 
twenty  days  with  a  healed  wound;  no  bile  was  discharged  after  fourteen  days. 

The  second  patient  was  a  female  of  thirty-four  years.  In  removing  a  gall  bladder  which  was 
very  adherent  the  common  duct  was  completely  severed  and  the  ends  separated  to  such  an  extent 
that  it  was  difficult  to  locate  the  distal  fragment.  The  proximal  end  was  made  manifest  by  escape 
of  bile.  The  severed  duct  was  sutured  end  to  end  in  three  fourths  of  its  circumference  with  in- 
terrupted fine  catgut  sutures,  through  all  the.  coats  but  avoiding  the  mucous  membrane,  excepting 
at  its  margin.  The  sheath  was  treated  in  a  similar  manner.  It  was  not  possible  to  introduce 
more  than  five  to  six  sutures  in  all.  One  fourth  of  the  severed  duct  was  left  open  to  avoid  tension 
and  secure  free  drainage.  Bile  ceased  escaping  from  the  wound  on  the  sixteenth  day,  patient 
left  the  hospital  on  the  twenty-second  day. 

The  third  case  was  most  interesting.  A  female,  fifty  years  of  age,  with  stones  in  gall  bladder 
and  common  duct.  Gall  bladder  malignant,  involving  cystic  duct  and  extending  laterally  upon 
common  duct.  Gall  bladder,  cystic  duct,  and  one  inch  of  common  duct  excised.  The  duodenum 
and  head  of  pancreas  were  liberated  by  incising  the  peritoneum  and  loosening  the  cellular  attach- 
ments. This  enabled  the  distal  end  of  the  common  duct,  which  barely  projected  beyond  the  duode- 
nal shelter,  to  be  brought  to  the  short  end  of  the  hepatic  duct.  The  duodenum  was  secured  in  this 
situation  by  sutures  posteriorly.  The  common  duct,  which  was  dilated  to  the  size  of  a  lead  pencil, 
was  sutured  as  in  the  case  just  described.  One  fourth  was  left  open  for  drainage.  This  patient 
was  discharged  in  nineteen  days  with  a  healed  wound.  She  remained  well  for  seven  months,  but 
now  has  return  of  the  malignant  disease  shown  by  nodular  tumors  of  the  liver. 

In  two  additional  cases  the  common  duct  was  excised  for  malignant  disease.  In  the  first 
the  proximal  end  of  the  duct  was  united  to  the  duodenum  by  a  new  opening.  The  third,  a  malig- 
nant tumor  of  the  common  duct,  was  excised  with  end-to-end  suture.     Death  followed  from  shock. 

In  removing  stones  impacted  in  the  duodenal  end  of  the  common  duct,  great  difficulty  may  be 
encountered,  and  in  three  of  our  cases  it  became  necessary  to  open  the  duodenum  (McBurney), 
for  the  purpose  of  extracting  the  stone.  It  was  only  by  means  of  this  double  operation  that  the 
duct  could  be  properly  cleared.  The  duodenum  was  sutured  and  the  common  duct  drained  in,  the 
usual  manner.  In  a  fourth  case  the  duodenum  was  opened  for  the  removal  of  a  cancer  of  the 
ampulla  and  papilla.  All  of  these  cases  recovered.  I  cannot  too  strongly  urge  the  complete 
removal  of  all  stones  at  one  sitting,  if  the  patient  can  bear  the  operation,  and  in  our  experience  it 
has  been  safer  than  half-way  measures,  followed  by  unavailing  irrigations,  probing,  etc.,  and  in 
the  large  majority  of  cases  a  secondary  operation  of  greater  magnitude  than  the  first.  [W.  J, 
Mayo,  "  New  York  Medical  Record, "  1905.] 


410 


THE  jGALL  ducts 


Cliolecystenterostomy  is  an  operation  whieli  may  be  necessary  in  certain  rare 
cases  of  benign  inoperable  obstruction,  or  for  malignant  disease.    The  gall  bladder 


Fig.  459. — Button  as  held  when  pressed  together  when  performing  cholecystenterostomy. 


should  be  attached  to  the  duodenum  either  by  direct  suture  or,  preferably,  by  the 
employment  of  a  button,  the  ingenious  device  of  Prof.  J.  B.  Murphy.    The  technic 

is  as  follows:  A  perpendicular  incision  is 
made  three  inches  long  and  three  inches 
from  the  right  of  the  median  line  over  the 
gall  bladder.  The  duodenum  and  gall  blad- 
der are  dravs'n  into  the  wound,  and  an  in- 
cision made  in  the  duodenum  large  enough 
to  admit  one  half  of  the  button  (Fig.  459). 
The  method  of  inserting  the  suture  to  tie 
around  the  button  is  shown  in  the  accom- 
panying cuts  (Figs.  460-  and  461).  The 
thread  should  be  inserted  before  the  bowel 
is  opened,  and  every  precaution  should  be 
taken  to  prevent  the  escape  of  any  bowel 
contents  into  the  peritoneal  cavity.  The 
same  form  of  suture  is  then  inserted  into  the 
gall  bladder  at  a  point  which,  after  trial, 
will  permit  the  two  surfaces  to  come  snugly 
l^iG.  460.  Fig.  461.  together.      Any   gallstones   that   are   present 

may  be  removed  before  the  button  is  in- 
serted. The  other  half  of  the  button  is  then  placed  in  the  gall  bladder,  the  suture 
tiedj  as  in  the  intestine,  and  the  approximation  made,    The  bile  passes  through  the 


THE   SPLEEN  411 

opening  in  the  button  into  the  duodenum,  and  usually  the  symptoms  of  Jaundice 
disappear.  After  adhesion  between  the  approximated  bowel  takes  place,  the  button 
drops  either  into  the  intestinal  tube  or  into  the  ball  bladder.  When  it  drops  into 
the  alimentary  canal  it  is  discharged  with  the  fjeces,  but  if  it  drops  into  the  gall 
bladder  it  will  cause  discomfort,  and  ma}^  ultimately  require  removal. 

In  five  cases  in  which  it  was  foimd  impossible  to  make  this  anastomosis  with 
the  duodenum,  a  loop  of  the  transverse  colon  was  substituted  by  W.  J.  and  C.  H. 
Maj'o,  using  the  ilurphy  button  as  for  duodenal  anastomosis.  In  each  of  these 
eases  the  result  was  as  satisfactory  as  when  the  duodenum  was  used.  There  were 
no  late  infections  of  the  bowel  tract  from  colonic  bacteria,  and  one  patient  lived 
six  years,  dying  from  an  independent  disease.  The  second  was  alive  and  well 
four  years  after  the  operation. 

Occasionally  it  will  be  found  that  calculi  have  drifted  so  far  toward  the  duo- 
denum as  to  necessitate  the  incision  of  this  intestine  immediately  over  the  opening 
of  the  common  duct,  removing  the  stone  from  the  duct  from  within  the  bowel,  as 
was  performed  by  Dr.  Charles  McBurney. 

"When  it  becomes  necessary  to  divide  or  exsect  a  portion  of  the  common  duct, 
the  ends  may  be  reunited  by  using  ten-day  chromic-acid  catgut,  the  needle  passing 
through  all  "the  structures  of  the  wall  of  the  duct  one  eighth  of  an  inch  from  the 
cut  ends.  Careful  capillary  drainage  should  be  secured  during  the  seven  or  eight 
days  in  the  process  of  repair. 

When  for  any  reason  the  lower  end  of  the  duct  cannot  be  utilized,  the  upper 
end  may  be  led  directly  into  the  duodenum  by  stitching  this  portion  of  the  intestine 
to  the  adhesions  which  have  resulted  from  the  inflammatory  process.  In  this  way 
dragging  away  from  the  uj^per  end  of  the  duct,  after  it  has  been  united  at  the 
opening  in  the  duodenum  by  suture,  may  be  prevented.  This  operation  has  been 
successfully  performed  by  W.  J.  Mayo. 

The  Spleen 

By  reason  of  its  frialjility,  the  spleen  is  more  liable  to  rupti^re  than  any  other 
organ  of  the  body.  Its  substance  may  be  torn  as  a  result  of  a  direct  blow  upon 
the  abdomen  or  by  an  indirect  injury,  as  a  severe  concussion  received  in  a  fall. 
Hasmorrhage  is  usually  profuse,  and  often  rapidly  fatal.  When  caused  by  a  pene- 
trating wound,  there  is  usually  an  escape  of  blood  through  the  wound  in  the 
abdominal  wall.  The  bleeding  may,  however,  be  entirely  internal,  as  in  the  case 
of  rupture  without  penetration.  The  symptoms  are  syncope,  with  more  or  less 
profound  shock,  which  comes  from  sudden  exhaustive  haemorrhage. 

Treatment. — With  a  penetrating  wound  followed  by  hajmorrhage,  the  indica- 
tions are  to  open  the  abdomen  at  once  either  through  the  wound  of  entrance  or 
sufficiently  near  it  to  control  the  bleeding  from  the  spleen.  The  temporary  arrest 
of  hfemorrhage  maj^  be  secured  by  packing  with  sterile  gauze,  and,  when  possible, 
the  injured  portion  of  the  organ  should  be  brought  through  the  abdominal  incision. 
At  times  it  has  been  found  expedient  to  surround  the  torn  portion  with  a  ligature, 
this  part  ultimately  separating.  In  small  punctured  wounds,  packing  with  ribbon 
gauze  should  be  done.  The  gauze  is  left  in  place,  with  one  end  brought  out  through 
the  abdominal  wound,  and  when  adhesions  have  formed  it  may  be  removed.  In 
order  to  reduce  blood  pressure  from  a  bleeding  spleen  (or  other  internal  organs), 
ligation  of  the  extremities,  after  the  method  of  Detmold,  should  be  done.  When 
the  bleeding  has  ceased  and  shock  is  still  threatened  from  loss  of  blood,  the  injection 
of  hot  normal  salt  solution  into  a  vein  may  be  done.  In  milder  cases,  two  or  three 
pints  of  this  solution,  to  which  is  added  a  tcacupful  of  strong  coffee  or  an  equal 
quantity  of  whisky  or  brandy,  may  be  throA\Ti  into  the  colon.  In  rare  instances, 
splenectomy  may  be  necessary  after  infection  following  an  injur}^ 

A  number  of  cases  are  recorded  in  which  the  spleen  has  been  successfully  re- 
moved on  aceormt  of  rupture,  both  with  and  without  a  penetrating  wound. 

Abscess  of  this  organ  may  be  single  or  multiple.  The  sjTnptoms  are  those  of 
tenderness  elicited  by  deep  palpation,  with  gradually  developing  sepsis.  Subphrenic 
abscess  of  the  left  side  is  occasionally  met  with  as  the  result  of  the  extension  of 


412  THE  PANCREAS 

an  infectious  process  following  gastric  ulcer,  or  from  a  preexisting  abscess  of  the 
spleen.  The  diiferentiation  of  abscess  between  the  diaphragm  and  the  spleen  and 
intrasplenic  abscess  is  practically  impossible  without  exploration.  The  treatment 
does  not  differ  materially  from  that  already  given  for  hepatic  abscess  or  subphrenic 
abscess  over  the  liver. 

Displacement  of  the  spleen  occurs  quite  commonly  from  tight  lacing,  and  is  apt 
to  follow  prolonged  enlargements  of  this  organ  due  to  malaria  or  to  simple  hyper- 
trophy, neoplasm,  etc. 

When  possible,  it  should  be  resutured  in  its  normal  position,  or,  failing  in  this, 
splenectomy  may  be  necessary. 

Cysts  of  the  spleen,  when  present,  may  be  diagnosticated  from  abscess  by  ab- 
sence of  tenderness  and  the  general  symptoms  of  infection.  Aspiration  with  a 
delicate  hypodermic  needle  will  assure  a  correct  diagnosis,  although  this  should  not 
be  done  until  every  prejjaration  is  made  for  immediate  oj)eration. 

Hernia  of  the  spleen  occurs  at  times  through  a  wound  of  the  abdominal  wall. 
If  the  prolapsed  portion  has  not  become  strangulated  or  hopelessly  infected,  it 
should  be  thoroughly  cleansed  with  hot  sterile  salt  solution,  flushed  with  1-3000 
mercuric  chloride,  and  again  with  a  normal  salt  solution,  clried,  and  returned  to 
the  peritoneal  cavitJ^  and  the  wound  immediately  closed.  On  account  of  its  deli- 
cate structure,  the  most  careful  handling  is  required.  If  the  organ  is  so  lacerated 
tliat  in  all  probability  bleeding  will  ensue  as  soon  as  the  stricture  is  released,  it 
will  be  advisable  to  throw  an  elastic  ligature  around  it  at  the  level  of  the  skin, 
apply  an  aseptic  dressing,  and  remove  at  once  the  greater  part  of  that  portion 
projecting  beyond  the  ligature. 

Splenectomy. — This  operation  is  contra-indicated  in  leukaBmia,  amyloid  spleen, 
hypertrojjhy  secondary  to  cirrhosis  of  the  liver,  for  secondary  malignant  diseases, 
and  in  all  the  essential  anfemias.^  It  may  be  considered  in  certain  forms  of  localized 
tuberculosis  and  sarcoma.  When  the  organ  is  displaced  and  the  pedicle  is  long, 
the  operation  is  not  difficult,  but  when  it  is  closely  lodged  beneath  the  vault  of  the 
diaphragm,  a  very  long  abdominal  incision,  which  splits  the  left  rectus  muscle  and 
permits  of  Meyer's  costoplasty,  will  be  advisable.  The  splenic  vessels  should  be 
tied  separately  with  silk  or  linen  ligatures. 

With  abscess,  if  drainage  can  be  successfully  accomplished,  it  is  preferable  to 
splenectomy.  In  cysts,  benign  tumors,  tuberculosis,  and  sarcoma,  splenectomy  is 
the  operation  of  choice,  unless  in  the  non-malignant  diseases  a  tumor  is  so  small 
that  partial  splenectomy  may  be  entertained.  Davis  states  that  in  the  severe  type 
of  malarial  spleen,  with  failure  of  relief  of  the  malaria  or  the  extreme  enlargement 
by  medical  treatment,  splenectomy  will  often  result  in  cure. 

The  Pancreas. — One  of  the  most  frequent  lesions  of  this  organ  is  an  acute  or 
chronic  inflammation  (pancreatitis),  not  infrequently  associated  with  infection, 
with  partial  or  complete  occlusion  of  the  common  gall  duct.  Infection  in  all 
probability  occurs  through  the  communication  of  the  pancreatic  duct  with  the  liile 
duct,  although  infection  by  direct  extension  through  the  tissues  or  by  metastasis 
is  possible. 

In  twenty-six  cases  operated  upon  at  the  ]\Iayo  clinic,  a  chronic  infection  of  this 
organ  was  treated  with  satisfactory  results  by  drainage  of  the  bile  ducts.  The 
symptoms  of  pancreatic  infection  do  not  differ  materially  from  those  of  a  local 
peritonitis,  and  cannot  be  positively  differentiated  without  exploration,  which  should 
be  done  upon  the  appearance  of  the  first  symptom  of  intra-abdominal  infection  in 
this  region. 

The  operative  route  is  transperitoneal,^  following  a  free  incision  in  the  median 
line  about  half-way  between  the  xyphoid  appendix  and  the  umbilicus,  to  be  en- 

'  D.  B.  Da\as,  "Journal  American  Medical  Association,"  1905. 

'  In  two  cases  operated  upon  by  Dr.  George  E.  Brewer,  the  following  method  was  employed: 
A  median  incision  10  cm.  long  was  made  through  the  left  rectus  muscle.  The  transverse  colon 
with  its  omentum  was  turned  upward  and  the  body  of  the  pancreas  palpated  through  the  transverse 
mesocolon.  As  soon  as  the  indurated  area  was  appreciated,  the  intestines  were  walled  off  by 
gauze  pads  and  the  presence  of  pus  discovered  by  an  exploring  needle.  A  long  rubber  drainage- 
tube  about  three  sixteenths  of  an  inch  in  diameter,  was  introduced  into  the  small  opening  through 
fhe  inferior  layer  of  the  mesocolon,  and  tightly  packed  about  with  a  thin  strip  of  folded  gauze 


MESENTERY  AND  OMENTUM  4l3 

larged  upward  or  dowDward,  or  transversely  if  necessary,  to  meet  the  indications. 
Tlie  gastrocolic  omentum  should  be  incised  or  torn,  and  all  bleeding  promptly 
arrested.  By  traction  upward  upon  the  stomach  and  downward  upon  the  transverse 
colon,  the  posterior  layer  of  the  peritonaeum  which  covers  the  pancreas  is  incised 
and  the  organ  exposed.^  If  there  are  evidences  of  extensive  involvement  of  the 
head  of  the  gland,  in  addition  to  drainage  of  the  principal  bile  ducts  one  or  more 
cigarette  drains  or  a  temporary  gauze  pack  may  be  considered.  If  the  tail  of  this 
organ  is  involved,  removal  of  that  portion  is  the  only  alternative. 

Tuberculosis  of  the  pancreas  is  occasionally  met  with,  and  may  at  times  give 
rise  to  the  ordinary  symptoms  of  tumor.  After  exploration,  any  immediate  surgical 
indications  should  be  met  and  the  proper  general  hygienic  routine  prescribed. 

Calculus  of  the  pancreas  occurs  in  rare  instances,  and  may  possibly  be  diag- 
nosticated by  the  X-ray.  Much  more  reliable,  however,  is  the  careful  palpation 
of  this  organ  througli  an  exploratory  incision. 

Carcinoma  is  located  almost  always  in  the  head  or  larger  portion.  It  is,  as  a 
rule,  accompanied  by  chronic  progressive  jaundice,  dilatation  of  the  gall  bladder 
due  to  obstructive  pressui-e,  and  there  is  the  usual  wasting  cachexia  of  carcinoma. 
Tumefaction  is  of  slow  development,  and  not  readily  appreciated  on  account  of  the 
great  depth  of  this  organ. 

A  not  infrequent  lesion  of  the  pancreas  is  cyst,  which  may  be  of  traumatic 
origin  or  result  from  hematoma  due  to  extravasation.  Cysts  due  to  pathological 
changes  in  the  glandular  apparatus  occasionally  develop  in  the  pancreas,  and  may 
assume  very  large  proportions.  When  so  extensive  as  to  render  extirpation  impos- 
sible, they  should  be  tapped  through  an  incision  and  drained,  but  when  seen  early 
a  complete  removal  is  advised. 

Mesentery  and  Omentum. — While  cysts  of  the  mesentery  are  not  infrequently 
encountered,  solid  neoplasms  are  rare.  Cancer  may  be  primary,  but  is  more  often 
secondary.  Sarcoma  is  most  frequently  observed.  Fibroma  and  fibrosarcoma  are 
the  neoplasms  which  are  most  often  brought  to  the  attention  of  the  surgeon.  These 
tumors  should  be  removed  as  soon  as  discovered,  and  this  requires  at  times  the 
resection  of  that  part  of  the  alimentary  canal  to  which  the  blood  vessels  involved 
in  the  tumor  are  distributed. 

There  is  a  form  of  cyst  found  in  this  membrane  which  is  so  closely  related 
to  the  lacteal  system  that  it  is  supposed  to  originate  in  obstruction  of  these  ducts, 
although  one  ojjserver  (Dowd)  holds  that  they  are  of  embryonic  origin.  They  are 
multilocular,  in  color  cream  white,  with  large  vessels  traversing  their  walls.  They 
may  occur  at  any  time  of  life,  from  ten  years  old  and  upward.  Dr.  Miles  P. 
Porter  -  concludes  from  a  careful  study  of  this  subject  that  chyle  cysts  of  the 
mesentery  are  rarer  than  the  serous  variety.  The  treatment  consists  in  removal 
by  that  teehnic  which  seems  best  adapted  to  the  case  in  hand,  as  demonstrated  by 
exploration  (Porter). 

The  omentum  is  less  frequently  the  seat  of  neoplasms  than  the  mesentery,  al- 
though primary  sarcoma  of  the  omentum  is,  in  rare  instances,  encouniered.^  Cysts 
and  other  tumors  are  occasionally  met  with  here,  and  in  common  with  sarcoma  re- 
quire exploration  for  diagnosis,  and,  when  possible,  extirpation.  In  all  cases  of 
tumor  which  the  microscope  has  demonstrated  to  be  sarcoma,  either  with  or  without 
removal  by  operation,  the  injection  of  mixed  toxines  should  be  advised. 

tape  to  prevent  leakage.  The  tube  and  the  gauze  packing  were  secured  in  place  by  a  single  stitch 
of  plain  catgut.  The  distal  extremity  of  the  gauze  tape  and  long  drainage-tube  were  brought  out 
at  the  lower  angle  of  the  wound  leaving  ample  space  for  the  transverse  colon  and  small  intestines 
to  resume  their  normal  place.  The  tube  and  tape  were  allowed  to  remain  in  place  for  eight  days. 
Both  patients  recovered     ("Surg.  Gyn.  and  Obst.,"  September,  1907). 

1  F.  Vilas,  "Semaine  Medicale,"  October  11,  1905.  Murphy,  General  Surgery,  1906,  reports 
106  cases  of  acute  pancreatitis  surgically  treated,  of  which  more  than  50  per  cent  recovered. 

^  "Annals  of  Surgery,"  1906. 

3F.  Cobb,  "Annals'of  Surgery,"  July,  1906. 


CHAPTER    XXII 

OBSTRUCTION-  OF  THE  ALIJIENTAET  CANAL  BELOAV  THE  PYLORUS FOREIGN  BODIES 

BILIARY     CALCULI INTUSSUSCEPTION VOLVULUS CONSTRICTION    BY    BANDS 

STRANGULATION    THROUGH    SLITS    IN    THE    OMENTUM    AND    MESENTERY — DI- 
VERTICULA  NEOPLASMS STRICTURE ABDOMINAL     SECTION     FOR     INTESTINAL 

OCCLUSION RESECTION INTESTINAL   ANASTOMOSIS 

Partial  or  complete  occlusion  of  the  alimentary  canal  may  occur  from  a  variety 
of  causes,  namely:  (1)  impaction  of  fecal  matter,  (2)  foreign  bodies,  (3)  intus- 
susception, (4)  volvulus,  (5)  constriction  by  bands,  (6)  by  adhesions,  (7)  omental 
and  mesenteric  slits,  (8)  diverticula,  (9)  neoplasms,  (10)  stricture,  (11)  true 
hernia. 

The  impaction  of  ingested  matter  may  occur  at  any  part  of  the  alimentary  canal, 
although  this  accident  occurs  in  the  great  majority  of  cases  in  the  large  intestine. 
The  caecum  and  ascending  colon  are  the  most  common  seats  of  fecal  impaction, 
the  sigmoid  flexure  next  in  order. 

The  symptoms  upon  which  a  diagnosis  is  made  are  the  jjresence  of  a  tumor 
in  the  line  of  the  colon,  which  is  not  painful  on  pressure,  may  be  molded  by  firm 
and  prolonged  compression,  is  movaljle,  and  has  formed  gradually.  In  the  sig- 
moid colon  and  rectum  digital  exploration  or  inspection  will  demonstrate  the 
nature  of  the  mass.  Vomiting,  tenderness,  and  shoclc,  so  common  in  acute  ob- 
struction, are  absent,  or,  if  jjresent,  only  occur  in  the  latter  stages  and  in  extreme 
cases. 

The  treatment  consists  in  the  repeated  injection  of  warm  water  until  the  bulk 
of  the  tumor  is  softened,  when  laxatives  may  be  given  by  the  mouth.  The  method 
of  injection  is  as  follows :  Place  the  patient  in  the  knee-elbow  jjosition,  or  upon 
the  right  side  with  the  pelvis  elevated.  In  this  j)osition  the  pressure  is  in  great 
part  taken  ofE  the  rectum,  and  a  greater  degree  of  tolerance  is  ol^taincd.  The 
fountain  irrigator  is  the  best  instrument,  and  from  two  to  four  pints  or  more 
may  be  thrown  slowly  in  at  one  operation.  The  water  should  be  allowed  to  remain 
in  the  colon  as  long  as  possible.  When  the  impaction  is  near  the  anus,  it  may 
be  removed  with  the  finger  or  by  a  spoon.  Olive  oil  or  some  softening  and  lubri- 
cating agent  should  be  added  to  the  fluid  injected. 

Foreign  Bodies. — Indigestible  substances  of  various  kinds,  introduced  by  acci- 
dent or  intentionally,  at  times  pass  through  the  stomach  into  the  intestinal  canal 
and  become  lodged.     In  rarer  instances  they  are  introduced  through  .the  anus. 

Biliary  calculi  which  have  passed  through  the  common  duct  into  the  duo- 
denum, or,  causing  ulceration  of  the  gall  l^ladder  and  duodenal  wall,  enter  the 
canal  in  this  manner,  may  also  cause  intestinal  occlusion.  Again,  obstruction  has 
been  caused  in  a  number  of  instances  by  concretions  (enteroliths)  composed  of 
ingested  material  insoluble  in  the  gastro-intestinal  juices  and  from  which  the  mois- 
ture has  been  absorbed.     They  are  met  with  chiefly  in  the  colon  and  ajjpendix. 

The  symptoms  vary  with  the  suddenness  or  completeness  of  the  obstruction, 
as  well  as  with  its  location.  Sudden  occlusion  is  accompanied  by  a  rapid  pulse 
and  by  pain  of  a  colie]^}^  and  violent  character,  usually  referred  to  the  seat  of 
the  obstruction.  Shock  is  also  present  in  acute,  stoppage  of  the  canal.  Vomiting 
is  an  early  and  prominent  symptom  of  occlusion  of  the  small  intestine,  coming 
on  at  a  later  period,  when  the  colon  is  involved.  On  the  other  hand,  constipation 
is  a  feature  of  stoppage  in  the  large  intestine,  while  fecal  matter  in  varying 
quantity  may  continue  to  pass  per  anuin.  for  several  days  after  occlusion  above 

414 


OBSTRUCTION  OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS    415 

the  ileo-cecal  valve.  In  arriving  at  a  diagnosis,  palpation  and  percussion  will 
be  of  value.  The  Imowledge  of  the  accident  when  a  body  has  been  swallowed 
will,  of  course,  establish  the  character  of  the  occlusion.  Insane  or  hysterical 
individuals  often  indulge  in  such  practices.  Biliary  colic  and  Jaundice  not  in- 
frequently precede  occlusion  from  calculi  Avhich  escape  by  the  common  duct, 
while  tenderness  in  the  region  of  the  liver  and  duodenum  must  be  present  in  a 
varying  degree  in  cases  of  perforation  of  the  duodenal  wall  by  large  calculi  from 
the  gall  bladder. 

Tenderness  is  also  present  in  cases  where  delicate  sharp  objects  (pins,  needles, 
etc.)  have  passed  through  the  walls  of  the  intestine  and  are  wandering  in  the 
cavity  of  the  peritonaeum  or  in  the  pel-vis. 

The  treatment  which  should  be  instituted  in  obstruction  by  foreign  bodies  will 
depend  in  great  part  upon  the  symptoms  which  ensue.  If  the  occlusion  is  com- 
plete and  the  symptoms  are  alarming,  operative  interference  should  not  be  de- 
layed. The  only  doubt  which  may  be  thrown  upon  the  propriety  of  operating  is 
the  presence  of  shock  or  collapse  in  an  extreme  degree.  If  this  condition  is  pres- 
ent, morphia  and  whisky  hypodermically  should  be  administered  in  the  effort 
to  bring  about  reaction.  If  no  urgent  S3Tnptoms  follow  the  presence  of  a  foreign 
body  in  the  alimentary  canal,  expectant  measures  may  be  employed  in  the  hope 
that  it  may  pass  out  by  the  rectum.  When  a  foreign  body  has  been  swallowed 
and  has  gone  beyond  the  stomach,  and  its  shape  is  known  to  be  such  that  it  may 
cause  perforation  of  the  intestinal  wall,  or  that  the  possibility  of  its  being  passed 
through  is  remote,  it  is  the  wiser  policy  not  to  lose  valuable  time  by  procrasti- 
nation, but  to  operate  at  once.  When  introduced  through  the  anus  or  lodged  in 
the  rectum  or  lower  portion  of  the  sigmoid  flexure  of  the  colon,  it  may  be  removed 
through  the  natural  opening. 

Intussusception,  or  the  telescoping  of  one  part  of  the  intestinal  canal  into  an- 
other may  occur  at  any  portion  of  the  bowel. 

It  is  most  frequent  in  infancy,  being  at  that  time  of  life  the  most  common 
cause  of  intestinal  obstruction.  In  the  small  intestine,  it  is  called  enteric;  in  the 
colon,  colic;  and  when  occurring  at  the  ileo-cacal  valve,  ileo-ccecal  intussusception. 
Multiple  invagination  in  the  small  intestine  is  not  infrequentlj'  found  on  autopsy 
in  children  in  whom  no  symptoms  existed  before  death,  and  which  evidently  oc- 
curred in  the  last  few  minutes  of  life. 

Dr.  L.  Emmet  Holt  collected  385  cases  of  intussusception  under  three  years 
of  age.  Of  these,  28  were  under  four  months  old;  113  were  between  four  and  six 
months  old;  71  between  seven  and  nine  months;  18  between  ten  and  twelve  months; 
32  between  one  and  two  years;  96  between  two  and  ten  j'ears.  Three  fourths  of 
all  the  cases  occurred  in  children  in  the  first  two  years  of  life,  and  one  half  be- 
tween the  fourth  and  ninth  months.  It  is  more  frequently  met  with  in  males 
than  in  females,  in  a  proportion  of  174  to  91.  Its  association  with  any  general 
disease  is  too  infrequent  to  be  of  any  importance.  It  is  caused  by  irregular  action 
of  the  muscular  walls  of  the  intestines.  One  part  of  the  tube,  by  reason  of  irri- 
tation, becomes  stiff  and  small  by  contraction  of  the  circular  muscular  fibers, 
while  the  part  immediately  below  is  relaxed,  and  into  this  the  smaller  and  stiff- 
ened part  telescopes  or  is  propelled  hj  the  force  of  a  downward  peristalsis.  The 
mesentery  is  drawn  in  v/ith  the  bowel.  Intussusception  need  not  necessarily  cause 
obstruction  and  strangulation,  but  in  most  cases  both  are  present,  and  produce  the 
usual  symptoms  of  occlusion.  Gangrene  may  occur,  due  to  strangulation  of  the 
mesentery  as  it  becomes  crowded  in  with  the  invaginating  gut.  In  some  instances 
parts  of  the  gangrenous  intestine  are  passed  by  the  rectum.  The  symptoms  are 
those  of  sudden  and  severe  pain  and  vomiting,  almost  always  following  enteritis 
or  colitis  which  has  induced  straining  at  stool,  shock,  tenesmus,  especially  when 
the  tumor  is  low  dowTi  toward  the  rectum,  and  bloody  and  mucous  evacuations. 
The  tumor  then  may  be  felt  on  the  left  side  along  the  sigmoid  flexure,  or  by 
rectal  examination.  '  It  is  often  felt  near  the  cagcum.  The  abdomen  is  not  dis- 
tended in  the  early  stages  of  the  disease,  but  later,  when  obstruction  becomes  estab- 
lished, tympanites  is  well  marked.  The  pain  is  usually  intermittent,  as  in  colic, 
and  is  excruciating  during  the  attacks.     The  most  marked  symptom  is  the  passing 


416    OBSTRUCTION  OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS 

of  blood  or  bloody  mucus.  The  temperature  during  the  first  twenty-four  or  forty- 
eight  hours  usually  rises,  but  may  be  normal  or  subnormal  in  the  early  stages  of 
the  attack,  due  to  shock.  The  prognosis  depends  on  the  age  of  the  patient  and 
the  character  of  the  invagination.  If  it  is  recognized  within  the  iirst  few  hours 
and  energetically  treated,  the  death-rate  will  be  very  much  lower. 

Treatment. — Immediate  operation  is  indicated.  If  the  tumor  can  be  recog- 
nized the  incision  should  be  as  nearly  over  it  as  possible,  always  witli  due  regard 
to  the  prevention  of  post-operative  hernia  {vide  Celiotomy).  If  in  doubt  as  to 
the  exact  point  of  invagination  a  limited  exploratory  incision  should  be  made  in 
the  linea  alba  below  the  umbilicus,  and  this  may  be  enlarged  up  or  down  as  re- 
quired. In  recent  cases,  before  adhesions  have  formed,  traction  and  counter- 
traction  will  release  the  imprisoned  segment.  Should  this  be  impossible,  and  the 
condition  of  the  patient  will  justify  a  major  procedure,  excision  and  direct  re- 
union is  imperative;  if  not,  an  artificial  anus  should  be  made.  In  case  gangi-ene 
has  occurred,  excision  should  be  done  without  regard  to  the  general  condition  of 
the  patient,  unless  the  entire  necrotic  portion  can  be  brought  outside  the  abdomi- 
nal wall.  When  the  invagination  is  recent,  after  the  patient  is  completely  relaxed 
by  the  anaesthetic,  the  following  conservative  measure  may  be  cautiously  tried : 

The  i)atient,  completely  relaxed,  is  placed  upon  the  back  with  the  thighs  flexed, 
and  the  table  inclined,  so  that  the  head  may  be  considerably  lowered.  Inflation 
through  the  rectum  and  colon  or  the  injection  of  liquid  may  be  employed.  Infla- 
tion is  preferable  for  the  reason  that  it  is  somewhat  more  easy  to  determine  when 
reduction  has  been  accomplished  by  air  than  by  water.  Danger  of  intestinal  rup- 
ture is  not  very  great,  as  it  occurred  only  once  in  two  hundred  and  twenty-five 
cases  in  children.  An  ordinary  hand  bellows  can  be  used  with  a  long  catheter 
attached,  introduced  well  up  in  the  colon.  The  introduction  of  air  should  be 
effected  gradually,  and  its  escape  prevented  by  pressing  the  buttocks  closely  to- 
gether. Manipulation  of  the  tumor  is  advised  while  the  air  is  being  introduced. 
The  best  guide  as  to  the  quantity  of  air  to  be  introduced  is  the  distention  it  pro- 
duces. Fifteen  or  thirty  minutes  may  be  allowed  for  the  effort.  Wien  bellows 
cannot  be  obtained,  warm  water,  at  a  temperature  of  about  105°  F.,  may  be  sub- 
stituted. A  fountain  syringe  may  be  used,  and  the  pressure  increased  by  eleva- 
tion. The  quantity  of  water  should  be  determined  by  the  degree  of  fullness  felt 
along  the  line  of  the  colon.  The  water  should  be  allowed  to  escape,  and  if  the 
tumor  has  not  disappeared,  it  may  be  again  tried,  and,  failing  in  a  second  attempt, 
laparotomy  should  be  done.  Eecurring  intussusception  may  be  prevented  by 
pleating  or  wrinkling  the  mesentery  in  two  or  more  folds  parallel  with  the  weak- 
ened segment  of  gut,  by  inserting  chromicized  catgut  sutures. 

Volv'jlns,  or  twisting  of  a  loop  of  intestine,  occurs  usually  in  the  sigmoid 
flexure  of  the  colon,  although  the  remaining  portions  of  the  colon,  or  cfEcum  and 
small  intestine,  may  be  occluded  by  this  accident.  The  loop  may  become  twisted 
upon  itself  at  its  mesenteric  attachment,  or  one  loop  may  he  twisted  over  a  second. 
The  last  variety  is  more  apt  to  occur  in  the  ileum  and  lower  jejunum.  The  prin- 
cipal cause  of  volvulus  is  an  abnormally  long  mesentery,  allowing  unusual  free- 
dom of  motion  to  the  loop  of  intestine  which  is  attached  to  it.  This  defect 
may  be  congenital  or  acquired.  Constipation  and  the  habitual  distention  of  the 
sigmoid  flexure  by  fecal  matter  is  probably  the  most  frequent  cause  of  elongation 
of  the  mesocolon  and  increased  length  of  this  part  of  the  large  intestine.  Vol- 
vulus occurs  more  frequently  in  men  than  in  women,  and  is  met  with  in  adults 
more  than  in  children.  When  the  conditions  are  favorable,  a  suitable  position 
or  an  accident  in  movement  is  sufficient  to  rotate  the  loop  on  its  axis,  causing 
occlusion  by  the  weight  of  the  loop  and  mesentery  brought  to  bear  upon  a  limited 
surface.  The  symptoms  of  volvulus  are  those  of  acute  intestinal  obstruction.  Pain 
similar  to  that  of  colic  is  present  from  the  start.  Constipation  is  the  rule,  and 
indicates  the  sigmoid  colon  as  the  seat  of  the  lesion.  Tenesmus  is  present  in  a 
certain  number  of  cases,  and  is  additional  evidence  that  the  colon  is  involved. 
Distention  of  the  abdomen  to  an  extreme  degree  occurs  in  a  large  proportion  of 
cases,  developing  more  rapidly  in  volvulus  of  the  colon.  Vomiting  is  rarely  pres- 
ent until  late  in  the  history  of  the  case,  and,  when  it  appears  early,  it  suggests 


OBSTRUCTION  OP  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS    4l7 

obstruction  in  the  small  intestine.  A  condition  of  shock  more  or  less  profound 
suiDervenes  if  relief  is  not  obtained.  Diminution  in  the  quantity  of  urine  is  present 
in  a  certain  proportion  of  cases. 

Without  interference  the  prognosis  is  fatal  probably  without  exception  in  every 
case  of  complete  volvulus.  Strangulation  of  the  loop  and  gangrene  with  enormous 
distention  of  the  part  involved  occur. 

Treatment. — If  the  symptoms  point  to  the  sigmoid  flexure  or  colon  as  the 
seat  of  the  twist,  the  introduction  of  warm  water  into  the  rectum  is  indicated. 
The  patient  should  be  placed  in  the  knee-elbow  position.  The  introduction  sliould 
be  made  gradually,  and  may  prove  successful  in  recent  cases  where  adhesions  have 
not  occurred,  or  where  the  distention  of  the  gut  is  not  too  great.  If  this  measure 
is  not  successful  within  a  few  minutes,  abdominal  section  should  be  performed 
and  the  loop  untwisted,  or,  if  gangrenous,  excised. 

Constriction  hy  Bands. — Bands  of  cicatricial  tissue  resulting  from  old  as  well 
as  acute  peritonitis  may  cause  intestinal  obstruction.  This  accident  occurs  chiefly 
in  adults,  about  equally  in  both  sexes,  being  due  to  pelvic  inflammations  in  women 
and  to  appendicitis  and  traumatic  peritonitis  in  men  (Treves).  The  bands  vary 
in  length,  breadth,  and  points  of  attachment.  The  lower  jejunum  and  ileum  are 
involved  in  almost  all  cases.  The  symptoms  are  in  general  those  of  acute  obstruc- 
tion of  the  small  intestine.  Pain  is  violent  in  the  beginning,  and  in  the  majority 
of  cases  is  referred  to  the  part  involved.  Vomiting  is  an  early  and  persistent 
symptom,  and,  as  is  common  in  obstruction  above  the  ileo-crecal  valve,  is  apt  to  be 
stercoraceous.  Shock  is  usually  more  prominent  in  this  form  of  occlusion  than 
in  those  heretofore  given.  The  urine  is  diminished  in  quantity.  The  abdomen 
is  not  tympanitic  as  a  rule,  although  the  constricted  loop  may  be  greatly  dis- 
tended, and  may  be  recognized  as  a  distinct  tumor  by  palpation  or  percussion, 
or  by  vaginal  or  rectal  exploration. 

The  diagnosis  must  be  made  from  the  history  of  a  former  peritonitis  and  the 
presence  of  the  symptoms  above  given.  The  prognosis  is  grave,  and  the  indication 
for  treatment  is  early  operative  interference. 

In  addition  to  inflammatory  bands,  intestinal  occlusion  is  occasionally  cairsed 
by  the  pedicle  of  an  ovarian  or  uterine  tumor,  or  the  Fallopian  tulje  may  act  in 
the  same  manner. 

Adhesions  between  contiguous  loops  of  intestine,  resulting  from  peritonitis, 
may  occur  in  such  a  manner  as  to  lead  to  occhision.  The  symptoms  do  not  differ 
materially  from  those  just  given,  and  the  treatment  is  the  same. 

Strangulation  through  Slits  in  the  Omentum  and  Mesentery. — Occasionally  a 
loop  of  intestine  slips  through  an  opening  in  the  omentum  or  mesentery,  becomes 
imprisoned  and  strangulated.  The  rent  may  be  congenital  or  result  from  an  in- 
jury, penetrating  or  non-penetrating.  The  small  intestine  (ileimi)  is  most  fre- 
quently involved,  and  the  aperture  occurs  as  a  rule  in  the  mesentery  of  the  last 
part  of  this  organ.  Strangulation  of  the  colon  in  this  manner  is  exceedingly  un- 
common. With  the  exception  of  the  presence  of  a  tumor,  the  symptoms  are  the 
same  as  those  in  hernia  of  the  small  intestine  with  strangulation.  Early  operative 
interference  offers  the  only  hope  of  relief. 

Constriction  by  Diverticula. — Pouches  or  cavities  communicating  with  or  at- 
tached to  the  intestines  may  be  true  or  false — i.  e.,  congenital  or  acquired.  Meckel's 
diverticulum,  which  is  attached  to  the  last  two  or  three  feet  of  the  ileum,  may 
remain  patulous  and  open  at  the  umbilicus,  or  more  frequently  it  ends  in  a  blind 
extremity  which  may  be  continued  as  a  cord  to  the  umbilicus.  When  it  exists  it 
represents  the  vitelline  duct  of  the  embryo,  in  which  the  normal  process  of  closure 
and  obliteration  has  not  taken  place.  The  vermiform  appendix  may  also  be  classed 
with  the  true  diverticula.  False  diverticula  occur  in  both  the  small  and  large 
intestine,  being  slightly  more  common  in  the  colon.  Their  mode  of  origin  is 
not  as  yet  satisfactorily  explained.  They  are  found  to  project  between  the  two 
layers  of  peritengeum  along  the  mesenteric  border  of  the  small  intestine,  and  into 
the  appendices  epiploica?  of  the  colon  (Treves).  They  are  herniis  of  the  mucous 
membrane  projecting  through  an  aperture  in  the  muscular  layer. 

Constriction  and"  strangulation  of  a  loop  of  intestine  by  Meckel's  diverticulum 


418    OBSTRUCTION   OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS 

are  much  more  apt  to  occur  than  by  the  false  pouches.  The  vermiform  appendix 
in  rare  instances  may  become  twisted  upon  its  axis  and  strangulated,  or  it  may 
cause  the  constriction  of  a  neighboring  loop  of  the  ileum. 

There  are  no  symptoms  peculiar  to  obstruction  from  true  or  false  diverticula, 
and  the  nature  of  the  lesion  can  only  be  discovered  by  abdominal  section,  which 
is  indicated  in  this  form  of  intestinal  occlusion.  W.  J.  Mayo  has  reported  a  num- 
ber of  cases  of  acquired  diverticula  of  the  colon  in  which  infection  occurred  with 
inflammatory  thickening  of  the  walls  of  this  gut  and  involving  the  peritonasum. 
The  true  nature  of  these  lesions  was  only  revealed  by  exploration  which  was  fol- 
lowed by  excision. 

Neoplasm^s. — Various  new  formations,  both  benign  and  malignant  in  char- 
acter, may  occur  in  the  intestinal  canal  and  lead  to  obstruction  by  projecting  into 
the  lumen  of  the  gut,  or  by  pressure  from  without  or  by  development  within  the 
wall  proper,  producing  narrowing.  Fibroma,  fibromyoma,  and  lipoma  are  of  rare 
occurrence.  Angeioma  is  also  exceptional  in  this  location.  Adenoma  is  a  more 
common  form,  developing  from  the  glandular  apparatus,  and  more  particularly 
from  the  follicles  of  Lieberklihn  in  the  large  intestine. 

Sarcom.a  and  carcinoma  are  also  met  with,  both  as  primary  and  secondary 
growths.  The  symptoms  of  obstruction  are,  as  a  rule,  gradual  in  development,  and 
the  presence  of  a  tumor  may  be  recognized  by  palpation  with  the  abdominal  mus- 
cles in  complete  relaxation.  Cancer  is  the  most  common  of  these  new  formations, 
and  is  apt  to  be  located  in  the  colon  or  rectum.  According  to  Haussmann  and 
Treves,  the  variety  of  cancer  met  with  in  the  large  majority  of  instances  is  a 
cylindrical  epithelioma,  eneephaloid  and  scirrhus  being  very  exceptional.  The 
growth  may  cause  constriction  by  extending  completely  around  the  lumen  of  the 
tube,  or,  by  developing  on  one  side,  cause  stenosis  by  its  bulk  and  by  the  contrac- 
tions which  result.  The  'diagnosis  of  cancer  may  be  made  in  those  cases  in  which 
the  disease  is  situated  in  the  rectum  or  lower  portion  of  the  sigmoid  flexure  by 
digital  examination  or  by  the  aid  of  the  speculum.  Situated  higher  up,  the  pres- 
ence of  a  tumor,  the  age  of  the  ]3atient  (over  forty  as  a  rule),  and  the  peculiar 
cachexia  will  aid  in  arriving  at  a  correct  diagnosis. 

Stricture. — The  partial  or  complete  occlusion  of  an  intestine,  by  cicatricial 
contractions  following  inflammation  ot  ulceration  of  its  mucous  and  submucous 
or  muscular  layers,  constitutes  a  true  intestinal  stricture.  Constriction  by  peri- 
toneal bands,  or  the  infiltration  accompanying  cancer,  is  not  considered  as  stric- 
ture jjroper. 

Any  disease  which  produces  loss  of  substance  in  the  inner  la3'ers  of  the  wall 
of  the  gut  may  produce  stricture.  The  ulcers  of  typhoid  fever,  tuberculosis,  dys- 
entery, syphilis,  and  chronic  intestinal  catarrh,  or  those  resulting  from  injury  by 
ingested  matter,  by  traumatism,  or  the  necrosis  following  strangulated  hernia, 
are  the  chief  lesions  which  precede  true  stricture  of  the  intestine.  Cicatriza- 
tion in  an  ulcer  which  has  its  longest  axis  at  a  right  angle  to  that  of  the 
intestine  is  more  apt  to  lead  to  obstruction  than  one  which  has  its  long  axis 
in  an  opposite  direction.  Stricture  occurs  in  adults,  of  forty  years  or  more, 
oftener  than  in  the  j'oung,  being  rarely  met  with  in  children  under  ten  years 
of  age.  No  portion  of  the  alimentary  canal,  from  the  pylorus  to  the  anus, 
is  exempt,  yet  stricture  of  the  duodenum  and  upper  jejianum  is  comparatively 
rare;  the  ileum,  near  the  cascum,  is  more  frequently  attacked,  while  the  large 
intestine,  and  especially  the  sigmoid  flexure  and  rectum,  is  the  most  common  seat 
of  this  grave  and  painful  affection. 

The  symptoms  of  stricture  are  those  of  progressive  narrowing  of  the  intestine. 
The  intensity  of  the  symptoms  will  be  proportionate  to  the  rapidity  with  which 
stenosis  results  and  to  the  portion  of  the  canal  involved.  Pain  is  not  marked  until 
the  narrowing  has  arrived  at  a  point  where  ingested  matter  passes  through  with 
difficulty.  It  is  spasmodic  in  character,  and  occurs  at  varying  intervals.  Dis- 
tention of  the  intestine  above  the  seat  of  stricture,  with  consequent  hypertrophy 
of  the  wall,  follows  sooner  or  later  in  all  cases.  The  continued  irritation  of  the 
bowel  from  the  pressure  of  fecal  matter  induces  ulceration  of  the  mucous  and  sub- 
mucous tissues  at  and  above  the  seat  of  stenosis,  and  joerforation  may  occur. 


OBSTRUCTION   OF  THE  ALBIENTARY  CANAL  BELOW  THE  PYLORUS    419 

Vomiting  is  an  earlier  symptom  in  stricture  of  the  ileum  and  jejunum  than 
when  the  colon  is  involved.  There  may  be  diarrhoea  or  constipation,  or  these  con- 
ditions may  alternate,  and  are  therefore  of  no  diagnostic  value.  Tenesmus  is  rare, 
and  the  abdomen  is  not  distended  except  in  case  of  peritonitis.  As  far  as  the 
previous  history  may  be  of  value  in  locating  the  seat  of  the  -lesion,  it  is  knowTi 
that  dysenteric  ulcers  are  nsuall}'  found  in  the  rectum,  sigmoid  flexure,  and  cfecum, 
and  in  the  order  of  frequency  in  which  these  organs  are  given:  typhoid  idcers 
(which  rarely  cause  stricture)  in  the  lower  ileum  and  caecum:  those  of  chronic 
catarrh  in  the  colon;  syphilis  (gumma)  in  the  rectum  and  ilemn;  and  tubercular 
ulcers  in  the  lower  ileum   (Treves). 

The  diagnosis  of  stricture  must  be  based  upon  a  study  of  the  symptoms  above 
given,  except  the  cases  in  which  the  lesion  is  in  the  rectum  or  lower  part  of  the 
sigmoid  flexure,  where  digital  or  instrumental  exploration  may  be  made. 

Treatment. — Stricture  of  the  rectum  and  lower  part  of  the  sigmoid  flexure 
of  the  colon  should  be  treated  by  dilatation  or  division.  Above  this  point  the 
only  hope  of  relief  is  by  exsection  of  the  part  involved  with  end-to-end  anastomosis, 
or  bj'  lateral  intestinal  anastomosis.  Enterostomy  and  colostomy  {fecal  fistula) 
are  palliative  surgical  measures,  to  be  instituted  when  other  means  are  not 
indicated. 

Abdominal  Section  for  Intestinal  Occlusion. — The  rules  governing  the  incision 
through  the  abdominal  wall  as  given  in  the  chapter  on  celiotom}^,  may  in  general 
be  applied  for  the  relief  of  intestinal  obstruction.  While  in  case  the  seat  of  the 
lesion  is  determined  it  is  most  convenient  for  the  operator  to  make  an  incision 
directly  over  the  point  of  obstruction,  as  before  stated,  this  should  not  be  done 
if  such  incision  will  permanently  weaken  the  abdominal  wall,  provided  there  is 
another  approach  near  by  which  can  be  so  closed  as  to  give  a  better  guarantee 
against  the  danger  of  abdominal  hernia. 

Wlien  exploration  is  necessary,  the  linea  all^a  is  in  general  preferable.  The 
opening  should  at  first  be  just  large  enough  to  admit  one  or  two  fingers,  and  it 
may  be  enlarged  or  abandoned  as  required. 

For  the  ca?cum,  the  ileo-crecal  region,  and  ascending  colon,  splitting  the  right 
rectus  is  advised.  To  this  may  be  added  a  separate  opening  farther  out,  after 
the  method  of  ilcBurney.  The  hepatic  flexure  of  the  colon,  the  duodenum,  and 
upper  jejunum  may  be  reached  through  the  right  rectus  above,  the  stomach  and 
transverse  colon  through  the  median  line,  while  the  splenic  flexure  and  descending 
colon  are  best  approached  through  the  left  rectus,  with  or  without  a  combination 
with  a  JIcBuiney  separation  on  this  side.  For  obstructive  lesions  in  the  left  in- 
guinal region  for  a  major  procedure,  a  split  of  the  rectus  should  be  preferred  with 
the  alternative  of  the  McBurney  method  nearer  the  crest  of  the  ileum. 

In  general,  the  smaller  the  incision  the  better,  yet  the  opening  should  always 
be  sufficient  to  admit  of  thorough  exploration,  and,  if  necessary,  inspection.  The 
patient  should  rest  upon  the  Ijack,  with  the  head  and  shoulders  slightly  elevated, 
in  order  to  relax  the  aljdominal  muscles.  Under  certain  conditions  the  Trendelen- 
burg posture  more  or  less  modified  is  advisable. 

If,  upon  exposing  the  small  intestines,  some  of  the  coils  are  found  to  be  greatly 
distended  while  others  are  collapsed,  it  is  pretty  safe  to  conclude  that  the  obstruc- 
tion is  near  at  hand,  and  the  collapsed  loops  should  he  carefully  passed  between 
the  fingers  up  to  the  oljstruction.  It  is  scarcely  possible,  in  the  condition  in  which 
the  viscera  will  be  found,  to  determine  exactl}'  which  is  the  upward  or  downward 
direction  of  the  coils,  and  it  may  be  necessary  to  begin  at  the  caecum  and  work 
upward. 

Senn  determined  by  experimentation  that  by  touching  the  pieritoneal  surface 
of  the  bowel  with  a  little  powdered  chloride  of  sodium,  a  reversed  peristalsis  will 
ensue.     In  this  way  the  upward  direction  of  the  Ijowel  may  be  recognized. 

ISTot  infrequently  the  intestines  are  so  enormously  distended  that  they  are 
protruded  through  even  a  small  incision  and  seriously  interfere  with  the  explora- 
tion.    Proceed  with  the  method  of  Dr.  George  H.  Monks  as  follows :  ^ 

The  first  distended  loop  of  small  intestine  is  brought  out  through  the  abdomi- 
'  "Annals  of  Surgery,"  October,  1903. 


420    OBSTRUCTION  OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS 

nal  incision,  and  a  No.  50  linen  purse-string  suture  is  inserted  in  the  shape  of 
an  ellipse  in  the  long  axis  of  the  gut,  the  ellipse  being  about  tliree  fourths  of  an 
inch  wide  and  about  an  inch  long.  A  gauze  packing  is  used  to  protect  the  peri- 
toneal cavity  from  soiling.  A  glass  tube  slightly  curved  near  the  end,  the  open- 
ing one  half  inch  in  diameter  on  the  concavity  of  the  curve  (a  straight  tube 
about  one  half  inch  in  diameter,  or  the  ordinary  glass  drainage-tube  will  suffice 
in  an  emergency),  to  one  end  of  which  a  long  piece  of  rubber  tubing  is  attached, 
is  introduced  into  the  lumen  of  the  gut  through  an  opening  made  along  the 
center  of  the  space  within  the  elliptical  purse-string  suture,  which  is  immediately 
tightened  around  the  cylinder  to  prevent  extravasation.  The  gaseous  and  semi- 
liquid  contents  flow  out  through  the  tube  into  a  receptacle.  When  the  flow 
ceases,  loop  after  loop  of  distended  gut  is  drawn  down  upon  the  tube,  the  oper- 
ation taking  time  enough  to  permit  the  escape  of  the  contents  of  each  loop.  As 
soon  as  the  upper  end  of  the  canal  is  emptied,  the  glass  tube  should  be  turned 
downward  into  the  lower  portion  and  the  process  of  emptying  repeated. 

In  this  way  the  distention  may  be  entirely  relieved,  and  if  necessary  it  may 
be  applied  to  hyperdistention  of  the  colon.  The  tube  is  then  withdrawn  and  the 
purse-string  suture  immediately  tied.  There  is  scarcely  any  constriction  of  the 
lumen  of  the  gut  by  tying  the  purse-string  suture,  and  the  slight  degree  of  angu- 
lation which  results  will  not  interfere  with  the  passage  of  ingesta.  One  or  more 
Lembert  sutures  may  be  superadded  to  the  purse  string  for  security. 

Emptying  the  intestines  by  this  procedure  not  only  diminishes  tension  and 
permits  the  return  of  the  bowels  to  the  peritoneal  cavity,  but  it  removes  a  large 
quantity  of  toxic  material  from  the  alimentary  canal,  and  thus  adds  to  the  chances 
of  recovery.  If  this  apparatus  is  not  at  hand,  multiple  puncture  may  be  substi- 
tuted, but  this  method  is,  unsatisfactory  since  a  single  puncture  will  rarely  empty 
more  than  one  or  two  feet  of  intestine. 

When  as  not  infrequently  happens,  by  reason  of  procrastination,  the  condition 
of  the  patient  is  so  critical  that  a  prolonged  operation  is  not  indicated,  it  is  the 
better  practice  to  seize  the  first  presenting  loop  of  distended  intestine,  stitch  it  to 
the  abclominal  wound,  and  establish  immediately  an  artificial  anus.  The  alarming 
symptoms  of  ol)struction  may  be  thus  allayed,  and  the  occlusion  dealt  with  at 
a  subsequent  operation.  I  have  in  a  number  of  instances  successfully  emjjloj'ed 
this  method,  restoring  later  the  continuity  of  the  canal. 

If  the  ca?cum  is  found  to  be  distended,  the  lesion  is  evidently  in  the  colon,  and 
this  organ  should  be  followed  to  the  obstruction.  If  biliary  calculi,  a  foreign 
body,  or  enteroliths  are  found,  the  part  involved  in  the  obstruction  should,  if  pos- 
sible, be  brought  out  at  the  wound,  protected  by  warm  towels,  the  escape  of  matter 
into  the  cavity  of  the  peritonfeum  prevented  by  napkins,  and  the  Ijody  removed 
by  an  incision  in  the  long  axis  of  the  gut,  and,  when  possible,  opposite  the  mesen- 
teric attachment.  The  length  of  the  opening  should  be  sufficient  to  allow  of  the 
removal  of  the  body  without  bruising  or  tearing.  If  the  part  cannot  be  brought 
out,  it  should  be  laid  upon  mats  and  the  peritonasum  in  this  way  protected  from 
the  escape  of  fecal  contents.  This  accident  may  be  in  great  part  prevented  by 
compression  of  the  gut  above  and  below  the  obstruction.  The  wound  in  the  intes- 
tinal wall  is  next  closed  by  Lembert's  suture. 

If  strangulation  and  necrosis  exist,  exsection  of  the  necrosed  jiortion  should  be 
made  at  once,  if  the  condition  of  the  patient  is  such  as  to  justify  a  prolonged 
operation.  If  not,  the  dead  loop  or  portion  should  be  brought  out  at  the  incision 
in  the  abdomen,  cut  away,  and  a  fecal  fistula  established.  In  this  emergency 
Bodine's  operation  may  be  found  of  great  value,  since  the  restoration  of  the 
intestinal  canal  may  be  accomplished  at  a  subsequent  operation  without  general 
narcosis.  If,  however,  operative  interference  has  not  been  too  long  postponed, 
it  will  be  advisable  to  proceed  with  the  exsection  at  once. 

Excision  of  a  portion  of  the  intestinal  canal  may  be  necessitated  as  a  result 
of  gangrene  following  strangulated  hernia,  intussusception,  volvulus,  vascular  oc- 
clusion, stricture,  neoplasm,  or  perforation  with  loss  of  substance  so  great  that 
lateral  closure  is  not  possible. 

The  operative  procedures  are  end-to-end  or  lateral  anastomosis,  or  the  estab- 


OBSTRUCTION   OF  THE   ALIMENTARY  C.^NAL   BELOW   THE   PYLORUS     421 

lishment  of  a  temporary  fecal  fistula.  The  choice  of  either  one  of  these  operations 
vnH.  depend  upon  the  conditions  which  prevail.  A  restoration  of  the  integrity 
of  the  canal  by  end-to-end  sutiire  is  the  ideal  procedure,  and  it  should  be  pre- 
ferred. If  the  patient's  condition  is  such  as  to  contra-indicate  a  prolonged  oper- 
ation, the  ilurpliy  button  or  lateral  anastomosis  may  be  substituted,  or  the  tem- 
porary fecal  fistula  shoidd  be  established  and  resection  performed  at  a  later  period. 

As  between  end-to-end  anastomosis  by  suture  or  the  ilurphy  button,  the  suture 
should  be  preferred  if  the  conditions  of  the  operation  are  favorable  and  the  oper- 
ator sufficiently  expert.     If  not,  the  button  should  be  given  preference. 

In  expert  hands  lateral  anastomosis  may  be  rapidly  performed  with  the  assist- 
ance of  the  douljle  clamp,  and  this  operation  is  given  preference  by  a  surgeon  of 
such  large  experience  as  W.  J.  Mayo. 

End-to-end  Anastomosis  by  Suture.- — The  loop  of  the  intestine  which  is  the 
seat  of  lesion  should  be  brought  out  through  the  incision  in  the  abdominal  wall. 
Gauze  shoidd  be  inserted  to  prevent  infection  of  the  peritoneal  cavity,  and  that 
portion  of  the  exposed  loop  not  in  the  field  of  operation  should  be  covered  with 
towels  wet  in  hot  salt  solution.  At  a  convenient  distance  on  either  side  of  the  pro- 
posed lines  of  incision  through  the  bowel,  it  should  be  clamped  by  forceps  shielded 
with  ruljber,  or  sterile  tapes  should  be  passed  through  the  mesentery  close  to  the 
bowel  and  tied  in  a  loose  half  bow-knot  sufficiently  tight  to  close  the  lumen  of  the 
gut,  while  not  exercising  pressure  enough  to  entirely  arrest  the  circulation  (Fig. 
4G2).     In  excising  the  necrotic  area  the  intestine  should  be  cut  across  at  a  right 


Fig.  462. — Loop  of  small  intestine,  a,  b,  Lines  of  section  througli  tlie  gut,  removing  the  gangrenous 
portion,  h,  c,  Same  througli  the  mesentery,  a,  a,  Gangrenous  portion  of  ileum,  d,  d.  Occlusion  of 
the  afferent  and  efferent  tubes  by  tape  ligatures. 

angle  to  its  axis  by  a  single  stroke  with  straight  scissors  (Fig.  462,  a,  h),  and 
these  lines  of  section  should  be  well  in  sound  tissue.  A  triangidar  piece  of  mesen- 
tery is  next  removed  (Fig.  463,  6,  c)  in  such  a  manner  that  the  mesentery  is  left 
projecting  nearly  one  quarter  of  an  inch  beyond  the  line  of  section  through  the 
intestine,  in  order  to  insure  the  vascular  supply  to  the  gut  at  this  most  important 
point.  All  bleeding  points  from  the  mesentery  should  be  tied  with  plain  catgut. 
Of  the  suture  methods  the  simplest  and  most  rapidly  executed  is  the  author's 
through-and-through  partly  continuous  suture,  which  is  interrupted  at  four  points 
in  the  circumference  of  the  gut  so  that  the  threads,  as  later  they  become  loose  and 
hang  in  the  lumen  of  the  bowel,  may  not  form  festoons  of  too  great  length.     The 


422  OBSTRUCTION  OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS 

material  employed  is  a  fine  (Ko.  50)  Pagensteclier's  celMoided  linen,  and 
preferably  dyed  black,  with  a  perfectly  round  ordinary  embroidery  or  sewing 
needle,  straight,  and  of  as  small  size  as  will  carry  the  thread.  These  needles  can 
be  used  rapidly  witliout  a  needle  holder,  and  make  only  a  small  pimcture,  which 
is  at  once  filled  with  the  suture,  so  that  the  chances  of  leakage  are  infinitesimal. 
The  two  ends  of  the  divided  intestine  are  flattened  and  placed  side  by  side  with 
the  cut  surfaces  parallel,  the  mesenteric  attachments  in  the  center  of  the  approxi- 


FiG.  462a. — Insertion  of  mesenteric  stitch,  which  obliterates  triangular  space.      (Connell.) 

mated  surfaces.  This  is  the  weak  point  in  the  operation,  and  considerable  care 
must  be  taken  to  prevent  leakage.  At  a  point  just  to  one  side  of  the  middle  of 
the  space  which  is  uncovered  by  peritonaeum  (Fig.  463  a)  and  a  little  more  than 
one  eighth  of  an  inch  from  the  cut  edge,  the  needle  should  be  carried  directly 
through  the  botvel  wall  and  then  out  through  the  cut  edge  of  the  divided  mesentery 
straight  across  to  the  other  side  through  the  layer  of  the  mesentery  of  that  side, 
then  through  the  bowel  wall  into  the  lumen  of  the  opposite  end  of  -the  gut.  At 
a  point  one  eighth  of  an  inch  removed  it  is  reentered  and  made  to  pass  again 
through  the  wall  and  out  through  that  layer  of  the  mesentery,  across  through  the 


Fig.  462&. — Stitches  inserted  and  all  tied  but  tlie  last  two.     These  in  place,  with  ends  ready  for  tying. 

(Connell.) 

opposite  mesenteric  layer,  and  then  again  through  the  bowel  wall,  coming  out 
one  eighth  of  an  inch  from  where  it  was  originally  introduced.  The  route  of 
this  suture  is  clearly  shown  in  Fig.  462  a.     It  should  be  tied  at  once. 

If  this   Connell  suture  is  not  employed,  the  next  best  method  at  this  point 
is  to  carry  a  single  interrupted  suture  through  the  center  of  the  inter-mesenteric 


OBSTRUCTIOX   OF   THE   ALDIEXTARY   CAXAL   BELOW  THE   PYLORUS     423 

space  and  one  eighth  of  an  inch  on  either  side,  another  which  shall  include  both 
the  bowel  and  the  layer  of  mesenterj'.  Either,  if  properly  employed,  shordd  suf- 
fice to  prevent  leakage.  The  Connell  suture  is  preferable,  since  it  can  be  more 
rapidly  introduced  and  time  is  always  a  factor  of  importance  in  intestinal  sur- 
gery. With  this  suture  inserted  and  tied,  a  through-and-through  suture  to  be 
used  as  a  holding  loop  should  be  inserted  at  the  limit  of  the  approximated  bowel 
surfaces  on  either  side  of  the  primary  suture.    While  an  assistant  holds  these  two 


Fig.  462c. — The  threaded  needle  presents  at  the  location  of  the  last  stitch.     The  ends  to  be  tied  are  in- 
serted into  the  loop  formed  by  the  needle  and  its  thread.     (Connell.) 

loops,  the  operator  rapidly  introduces  a  continuous  suture,  commencing  one  six- 
teenth of  an  inch  from  the  first  suture,  each  loop  being  one  eighth  of  an  inch 
long,  and  the  needle  introduced  slightly  more  than  one  eighth  of  an  inch  from 
the  cut  edge.  These  loops  should  be  drawn  tight  enough  to  firmly  approximate 
the  peritoneal  edges,  but  not  tight  enough  to  pucker  or  contract  the  lumen  of 
the  bowel.  When  the  holding  sutures  are  reached,  these  should  also  be  tied  and 
one  end  of  each  thread  used  as  a  continuous  suture  until  a  space  "of  about  one 


Fig.  462<?. — By  withdrawal  of  the  needle  and  its  loop,  the  cut  ends  at  the  site  of  the  last  stitch  are 
inverted,  and  the  ends  to  be  tied  are  drawn  to  the  outside  through  the  opposite  portion  of  the  line 
of  suture.     (Connell.) 

fourth  of  an  inch  is  still  unimited.  Here  they  should  be  tied,  the  knots  being 
upon  the  inner  or  mucous  surface,  and  the  remaining  gap  closed  by  two  inter- 
rupted sutures  inserted  from  the  mucous  side  of  the  bowel,  as  shown  in  Fig. 
462  &.  In  order  to  bring  these  last  knots  also  on  the  inner  side  of  the  bowel, 
they  are  to  be  tied  in  the  following  manner:  One  of  the  needles,  armed  with  a 


424    OBSTRUCTION   OF  THE  ALIMENTARY  CANAL  BELOW  THE   PYLORUS 

loop  of  sufficient  length  is  pushed  eye-end  foremost  through  the  suture  line  at 
a  point  about  opposite  that  at  which  the  last  sutures  are  inserted,  and  is  carried 
through  as  shown  in  Figs.  462  c  and  d.  Both  ends  of  one  of  the  final  sutures  is 
caught  in  the  loop,  which  is  then  withdrawn,  bringing  both  ends  out  through  the 
bowel  on  the  opposite  side,  where  they  are  temporarily  knotted  to  i^revent  con- 
fusion. This  is  repeated  for  the  remaining  suture,  when  the  ends  are  tightly  drawn 
and  tied,  which  brings  the  knot  on  the  mucous  surface.  The  ends  are  cut  short 
with  the  peritoneal  surface,  and  as  the  bowel  expands  they  slip  into  the  lumen, 
leaving  every  knot  tied  upon  the  inner  siirface  of  the  bowel. 

If  the  technic  of  this  through-and-through  suture  is  carefully  carried  out  as 
above  given,  it  in-volves  the  minimum  of  risk,  possessing  as  it  does  the  one  great 
advantage  of  rapidity  of  execution.  When  eomjjleted,  if  there  should  afijjear  to 
be  a  weak  point  in  the  line  of  union  a  simple  Lembert  suture  should  be  inserted 
by  way  of  reenforcement. 

In  the  hands  of  an  expert  operator,  anastomosis  by  the  combined  Mayo-Cush- 
ing  sutures  may  be  preferred,  especially  if  time  is  not  of  great  importance,  or 
if  the  surgeon  is  a  rapid  and  skillful  technician.  These  two  stitches  are  clearly 
illustrated  in  Fig.  445e. 

The  needle  carrying  the  Mayo  catgut  stitch  should  be  inserted  one  sixteenth 
of  an.  inch  from  the  cut  edge  for  the  small  and  one  eighth  for  the  large  intes- 
tine. It  is  commenced  on  one  side  of  the  mesenteric  attachment,  each  loop  of 
the  suture  being  one  eighth  of  an  inch  long.  When  the  first  stitch  is  tied,  the 
end  should  be  left  about  two  inches  long  to  be  finally  knotted  with  the  main  thread 
when  the  entire  circumference  of  tlie  cut  edges  have  been  imited.  Then  it 
shoixld  be  cut  short  and  the  knot  pushed  between  the  united  edges  into  the  lumen 
of  the  bowel.  The  Gushing  seronmscular  mattress  suture  is  now  sufieradded  in 
the  same  manner  as  desc'ribed  by  him  when  no  other  suture  is  employed. 

This  seromuscular  suture  line  is  intended  to  run  parallel  with  the  cut  edge  of 
the  intestinal  -wall  three  sixteenths  of  an  inch  (4.5  mm.)  from  the  edge.  The 
needle  is  inserted  parallel  with  the  cut  edge,  passing  through  the  serous  and 
the  muscular  layers,  taking  care  not  to  penetrate  the  mucous  membrane,  and  is 
made  to  come  out  one  eighth  of  an  inch  from  where  it  entered.  The  needle  is 
then  carried  directly  across  the  wound  to  the  other  cut  end  of  the  intestine  and 
the  same  procedure  is  there  repeated.  As  it  passes  from  one  end  of  the  gut  to 
the  other,  it  should  be  exactly  at  a  right  angle  to  the  cut  edge,  hence  Gushing 
calls  it  "  the  right-angled  continuous  suture."  It  is  begun  at  one  side  of  the 
mesenteric  attachment  by  what  he  terms  an  inverted  Lembert  suture.  This  is 
tied  at  once,  leaving  a  free  end  two  or  three  inches  long.  The  suture  is  then 
continued  along  that  part  of  the  intestine  where  the  two  layers  of  the  mesentery 
split  to  surround  the  gut,  and  on  to  complete  the  circumference,  when  the  thread 
forming  the  last  stitch  is  tied  to  the  free  end  of  the  first  or  Lembert  suture.  Both 
sides  or  layers  of  the  mesentery  are  now  sutured  by  inverted  Lembert  sutures  one 
eighth  of  an  inch  apart.  It  is  well  to  repeat  that  the  weak  point  in  end-to-end 
anastomosis  is  at  that  part  of  the  intestinal  circumference  in  close  relation  to 
the  mesentery  as  it  divides  to  surround  the  gut.  Extra  care  should  be  given  to 
this  portion  to  see  that  no  possible  leakage  may  occur. 

If  the  foregoing  technic  is  carefully  applied,  leakage  is  practically  impossible. 
The  Mayo  suture  of  absorbable  catgut  passing  through  the  entire  thickness  of  the 
intestinal  wall  is  so  inserted  that  as  it  is  tightened  a  strip  of  peritonteum  one 
sixteenth  of  an  inch  wide  (in  the  small,  one  eighth  in  the  large  intestine)  on  each 
end  of  the  gut  is  brought  in  close  apposition.  The  Gushing  suture  superadded, 
approximates  another  strip  of  peritonaeum  one  eighth  of  an  inch  wide,  and  as  this 
suture  line  does  not  become  infected  it  not  only  holds  the  peritoneum  in  apposition 
and  secures  rapid  plastic  union,  but  it  remains  innocuous  until  it  is  finally  absorbed. 
In  tightening  this  linen  suture,  Gushing  advises  that  it  be  drawn  just  tight  enough 
to  firmly  approximate  the  peritoneal  edges  without  diminishing  at  all  the  lumen 
of  the  intestines.     The  same  precaution  holds  good  with  the  Mayo  stitch. 

The  seromuscular  suture  of  Gushing  may  also,  when  time  is  a  matter  of  great 
importance,  be  alone  employed.    It  has  been  successfully  used  in  many  instances. 


OBSTRUCTION  OF  THE  ALIMENTARY  CANAL  BELOW  THE  PYLORUS  425 


After  irrigation  with  warm  salt  solution  the  clamps  are  removed  and  the 
sutured  loop  returned  to  the  peritoneal  cavity  (Fig.  463). 

When  the  loop  of  gut  cannot  be  drawn  out  through  an  incision,  sterile  mats 
should  be  used  to  wall  off  the  general  cavity  to  guard  against  infection. 

In  the  after-treatment  the  bowels  should  be  kept  at  rest  from  eight  to  ten 
days.     Nourishing  liquid  diet  and  articles  of  food  digested  and  absorbed  in  the 


Fig.  463. — Showing  the  line  of  sutu 


I  iitcry  and  around  the  intestine  m  one  of  the 


stomach  or  high  up  in  the  alimentary  canal,  or  in  the  lower  colon  when  this  is 
not  the  field  of  operation,  will  meet  the  indications. 

In  end-to-end  anastomosis  after  a  fecal  fistula  has  existed  for  some  time,  the 
lumen  of  the  bowel  below  the  opening  will  be  so  much  smaller  than  above  that 
it  will  be  necessary  to  insert  the  sutures  somewhat  nearer 
to  each  other  in  the  lower  circumference.  The  inequality 
will  disappear  as  soon  as  the  continuity  of  the  canal  is  re- 
stored. When  this  inequality  is  present  the  author  prefers 
to  use  the  interrupted  suture. 

Wlien  the  conditions  are  such  as  to  demand  a  more 
rapid  procedure  than  union  by  suture,  as  Just  described, 
the  employment  of  the  Murphy  button  may  be  substituted 
for  the  union  by  suture,  or  the  establishment  of  a  tempo- 
rary artificial  anus. 

These  buttons  are  made  of  vari- 
ous sizes  to  suit  difEerent  portions  of 
the  alimentary  canal. 

They  consist  of  two  small  circu- 
lar bowls  (Fig.  465)  so  arranged 
that  when  properly  adjusted  in  that 
portion  of  the  bowel  where  the  anas- 
tomosis is  to  be  made  they  close  to- 
gether by  a  double  ratchet  (Fig.  464) 

compressing  the  inverted  peritoneal  .  . 

surfaces  of  the  ends  of  the  intestine  and  securely  holding  these  m  apposition 
until  adhesion  occurs.  The  tliread,  which  has  tied  the  end  of  the  gut  around 
the  central  portion  of  each  segment  of  the  button  and  inverted  the  peritonmum, 


Fig.  464. — Murphy's  but^ 
ton.  The  segments 
pressed  nearly  to  com- 
plete closure. 


Fig.  465.  —  The  same — 
showing  construction  of 
the  separated  segments. 


426     OBSTRUCTION   OF   THE  ALIMENTARY   CANAL   BELOW  THE   PYLORUS 


becomes  loosened  by  necrosis  from  pressure,  and,  with  the  button,  in  from  seven 
to  fifteen  days  drops  loose  in  the  alimentary  canal  and  is  carried  along  until  it 
is  passed  through  the  rectum.  At  Fig.  466  the  method  of  passing  the  suture 
in  and  out  around  the  margin  of  the  bowel  is  shown.  With  a  straight  needle, 
armed  with  a  medium-sized  linen  suture,  carry  the  needle  through  the  bowel,  a 
little  more  than  one  eighth  of  an  inch  from  the  cut  edge  passing  through  the 
peritoneal  coat  and  into  the  lumen  of  the  gut.     One  fourth  of  an  inch  farther  on, 

the  suture  is  carried  on  the  same  level 
through  the  mucous  membrane  and 
out  through  the  peritoneum  to  the 
outside.  It  is  then  carried  over  the 
free  (cut)  edge  of  the  Ijowel  again  to 
the  inner  side  and  through,  and  this 
in-and-over  suture  is  continiied  (as 
shown  in  the  drawing)  until  tlie  bowel 
has  been  perforated  by  the  needle  from 
the  mucous-membrane  side  out  to  the 
peritoneal  surface  just  at  tlie  begin- 
ning of  the  attachment  of  the  mesen- 
tery to  the  intestine.  It  is  then  car- 
ried over  the  cut  edge  of  the  mesentery 
around  and  back  through  this  mem- 
brane at  the  same  depth  from  the  edge 
as  for  the  intestine,  then  back  again 
over  the  cut  edge  of  the  mesentery, 


Fig,  466. — Showing  the  in-and-out  method  of  in- 
serting the  silk  suture  around  the  end  of  the 
divided  intestine  and  over  and  through  the 
mesentery  near  its  attachment,  b,  Point  of 
beginning,     a,  Including  the  mesentery. 


Fig.  467. — One  segment  of  the  button  fastened 
in  one  end  of  the  intestine  (to  be  united) 
by  the  purse-string  suture  tied  at  b.  The 
complete  inversion  of  the  peritoneal  surface 
is  properly  accomplished. 


and  on  in  like  manner  as  for  the  opposite  side  of  the  gut  to  a  point  of  emer- 
gence about  one  eighth  of  an  inch  from  the  point  where  it  entered.  The  two 
ends  of  the  threads  are  now  ready  for  the  insertion  of  one  segment  of  the  button. 
This  is  grasped  by  the  forceps  and  carried  into  the  end  of  the  bowel  deep  enough 
to  allow  the  gut  to  be  snugly  folded  around  the  central  shaft  or  stem,  when  the 
two  ends  of  the  thread  are  tied  into  a  single  Imot  and  are  drawn  upon.  Like 
the  mouth  of  a  reticule  that  is  being  closed,  the  wall  of  the  intestine  is  folded 
and  puckered  until  it  fits  tightly  around  the  central  shaft  of  the  button,  as  shown 
in  Pig.  467,  where  the  threads  are  cut  off  close  to  the  knot. 

Examining  this  end  of  the  bowel,  it  is  readily  seen  that  when  the  opposite  half 
of  the  button  has  been  in  like  manner  applied,  and  has  been  pushed  into  this,  there 
would  be  nothing  but  the  peritoneal  surfaces  of  the  gut  in  contact.  If  the  mucous 
membrane  should  become  everted,  -  or  if  the  thread  is  not  so  thro\vn  over  the 
mesentery  as  to  invert  this  thoroughly,  and  bring  peritoneal  surfaces  in  apposition, 
there  will  be  failure  of  union,  sloughing,  and  perforation  at  these  points.     The 


OBSTRUCTION   OF  THE   ALIMENTARY   CANAL   BELOW  THE   PYLORUS     427 

whole  success  of  this  operation,  rests  upon  the  careful  application  of  the  button. 
The  other  half  of  the  button  is  applied  in  the  same  manner,  and  then  the  two 
are  brought  together  with  the  smaller  invaginated  into  the  larger.  By  pressing 
them  steadil}'  together  they  close  until  the  peritoneal  surfaces  are  snugly  in  con- 
tact, and  the  operation  is  completed.  In  this  operation,  as  in  end-to-end  suture, 
the  greatest  care  must  be  taken  to  prevent  any  foreign  substance  from  entering  the 
peritoneal  cavity. 

Exsection  and  reunion  of  the  colon  is  somewhat  more  difficult  than  the  opera- 
tion upon  the  small  intestine,  on  account  of  its  irregularity  in  size  and  the  deeper 
location  of  all  of  this  organ  except  the  transverse  portion.  It  should  be  brought 
into  or  out  of  the  incision  if  jjossible,  or,  if  this  cannot  be  done,  the  opening  may 
be  enlarged  in  the  direction  best  suited  to  the  case.  Experience  has  demonstrated 
the  faci  that~shoek  is  less  apt  to  follow  a  severe  operation  upon  the  colon  than 
upon  the  smaller  intestine.  ■ 

Lateral  intestinal  anastomosis  is  especiall)'  indicated  between  the  small  and 
large  intestine.     AVhen  the  parts  in  the  operative  field  can  be  brought  through 


Fig.  467a. — C.  F.  Roosevelt's  lateral  anastomosis  clamp.      ("Jr.  .\m.  Med.  Assn.") 


the  aljdominal  incision,  this  should  be  done.  After  the  required  excision,  the 
two  open  ends  should  be  closed  at  once  by  a  purse-string  suture  of  No.  50  linen 
with  two  or  three  Lembert  sutures  superadded  for  security.  A  free  portion  of 
that  side  of  the  colon  ojjposite  the  mesenteric  attachment  should  l:>e  caught  be- 
tween two  blades  of  the  clamp  (Figs.  4G7  a  and  h),  while  the  same  extent  of  the 


Fig.  4676. — The  same,  clamping  both  limbs  of  the  gut  to  be  united,     x  y,  Line  ot  section  through 

one  limb. 


smaller  intestine  is  fixed  between  the  remaining  blades.  The  sutured  line  of 
iinion  should  be  about  two  and  a  half  inches  long,  leaving  the  opening  of  com- 
munication two  inches  in  length,  so  that  in  the  contraction  which  naturally  fol- 
lows there  will  still  remain  a  free  passage  for  ingested  matter.  The  peritoneal 
surfaces  of  the  two  portions  of  gut  which  are  in  contact  should  be  at  first  secured 
by  the  Gushing  linen  suture.  About  one  fourth  of  an  inch  away  from  this  first 
row  an  incision,  parallel  with  the  suture  line  and  two  inches  long,  is  made  into  the 
wall  of  both  limbs  of  intestine,  and  their  contents  carefully  removed  by  bits  of 
gauze  so  that  no  soiling  may  take  place.  C.  H.  Mayo's  catgut  mucoserous  suture 
is  now  inserted  as  in  resection  of  the  stomach,  or  end-to-end  anastomosis  as  already 
described,  and  should  be  continued  throughout  the  entire  circumference  of  the 
opening  of  communication,  infolding  the  peritoneal  covering  and  firmly  uniting 
the  cut  edges.  The  remaining  half  of  the  Gushing  seromuscular  suture  is  now 
inserted  and  a  careful  toilet  made. 


CHAPTER    XXIII 

TYPHOID      ULCER TYPHLITIS PEEITYPHLITIC      ABSCESS COLITIS APPENDICOS- 

TOMY FLEXURE CARCINOMA    OF    THE    COLON    ANU    RECTUM     (mAYO'S    OPERA- 
TION)  TUTTLE's     OPERATION     FOR     COLOSTOMY BODINE's     OPERATION FECAL 

FISTULA 

Typhoid  Ulcer. — Perforations  from  typhoid  nicer,  unless  subjected  to  opera- 
tion, are  fatal  in  practically  all  cases.  So  low  is  the  condition  of  resistance  of, 
patients  who  have  suffered  from  typhoid  toxaemia  before  perforation  occurs,  that 
even  with  immediate  surgical  intervention  under  the  best  possible  conditions,  the 
death-rate  is  alarmingly  high. 

Comparing  Elsberg's  statistics  of  the  mortality  ratio  in  children  ^  with  those 
given  for  adults,  the  prognosis  is  much  more  favorable  in  very  young  than  in  adult 
or  elderly  subjects.  The  death-rate  at  this  date  may  be  jjlaced  in  general  at 
about  thirty  per  cent  in  children  and  about  seventy  per  cent  in  adults. 

Bymptoms. — According  to  J.  W.  Long  -  the  perforation  occurs  most  frequently 
during  the  third  week,  and  from  this  to  the  twenty-eighth  day,  although  it  may 
occur  later.  The  chief  symj)toms  are  a  rapid  rise  of  temperature  immediately 
after  perforation,  followed  in  some  instances  by  a  subnormal  register.  Pain,  very 
severe  in  character,  is  usually  present,  with  muscular  rigidity  and  tenderness  on 
pressure  with  rapidly  developing  tympanitis.  Vomiting  may  or  may  not  be 
present.  With  these  symptoms  in  a  patient  suffering  from  typhoid  fever  occur- 
ring between  the  sixteenth  and  thirtieth  day,  the  diagnosis  of  perforation  is  clear 
enough  to  justify  exploration. 

The  incision  should  be  made  through  the  right  rectus  muscle,  since  ninety- 
five  per  cent  of  perforations  occur  in  the  last  three  feet  of  the  ileum  (Haggard), 
while  seventy-three  per  cent  are  found  in  the  last  foot  of  the  small  intestine. 
According  to  Long,  in  exceptional  cases  it  may  occur  at  any  portion  of  the  ali- 
mentary canal,  even  in  Meckel's  diverticulum.     This  observer  says : 

"  Another  point  to  be  borne  in  mind  is  the  fact  that  in  sixteen  per  cent  the 
perforations  are  multiple.  Upon  opening  the  abdomen,  the  presence  of  free  fluid 
and  other  evidences  of  peritonitis  will  usually  be  found.  The  distal  portion  of 
the  ileum  with  the  CEecum  and  appendix  should  be  quickly  and  gently  examined. 
Perforations  should  be  closed  with  a  purse-string  suture,  being  careful  not  to 
make  too  great  tension." 

As  time  is  an  important  factor,  it  is  advisable  that  the  edges  of  the  ulcer  be 
not  trimmed,  but  simply  inverted.  If  they  are  multiple  and  involve  more  than 
one  half  of  the  wall  of  the  gut,  the  loops  should  be  drawn  through  the  incision 
and  a  temporary  fecal  fistula  established. 

If  there  has  been  any  escape  of  intestinal  contents,  a  careful  peritoneal  toilet 
is  imperative.  For  this  purpose  the  siphon-irrigating  apparatus  of  Blake  should 
be  preferred.  Drainage  should  be  employed  in  all  cases  at  the  seat  of  the  lesion, 
and,  when  there  has  been  general  peritonitis,  also  from  the  pelvis,  as  described 
in  the  article  on  general  suppurative  peritonitis.  As  an  anaesthetic  in  these  cases, 
nitrous  oxide  and  oxygen  should  be  employed,  and  when  this  is  not  available 
nitrous  oxide  and  air,  and,  last  in  order  of  preference,  ether. 

Certain  acute  and  chronic  inflammatory  lesions  of  the  large  intestine  demand 

>  "Annals  of  Surgery,"  May,  1903. 

^Paper  read  before  the  International  Surgeons'  Club  at  Rochester,  Minn.,  September  21,  1906. 

428 


TYPHOID  ULCER  429 

surgical  intervention.  Acute  inflammation  of  tlie  csecum  (typhlitis)  is  of  fre- 
quent occurrence,  and  is  at  times  so  severe  tliat  tlie  infection  spreads  either  in  the 
form  of  peritonitis  or  perityplilitic  abscess.  Wlaile  the  pus  collection  here  is  retro- 
peritoneal, peritonitis,  at  first  local,  is  always  a  complication  of  perityphlitis. 
The  differentiation  from  appendicitis  is  not  easy,  and  can  rarely  be  made  posi- 
tive except  by  exploration,  which  should  be  done  at  the  earliest  possible  moment 
in  all  cases  of  infection  in  this  region. 

In  delayed  retroperitoneal  abscess  the  pus  may  drift  toward  the  right  lumbar 
region,  where  it  can  be  reached  by  incision  and  drainage. 

In  cases  operated  upon  early,  the  regular  incision  for  appendicitis  is  advised, 
at  which  time  the  appendix  if  involved  may  also  be  removed,  together  with  all 
septic  fluid  or  exudate.  The  question  of  drainage  must  be  determined  by  the 
conditions  present.  The  methods  given  for  the  after-treatment  of  infection  for 
appendicitis  will  aj)ply  equally  well  in  perityphlitic  abscess  or  beginning  retro- 
peritoneal infection. 

In  obstinate  cases  of  chronic  colitis,  when  irrigation  by  the  rectum,  together 
with  careful  dietetic  treatment  and  medication  have  failed  to  afford  relief,  a 
cure  may  be  effected  by  surgical  drainage  and  irrigation  from  the  caecum  to  the 
rectum  by  the  operation  known  as  appendicostomy.  Through  a  McBurney  inci- 
sion one  or  two  fingers  are  introduced,  the  head  of  the  caecum  lifted  to  the  opening 
through  the  peritoneum,  and  the  appendix  drawn  out  until  it  is  in  contact  with 
the  abdominal  peritonaeum,  where  it  is  firmly  held  until  the  margins  of  the  incised 
peritoniKum  are  attached  by  sutures  of  fine  silk  or  linen  to  the  wall  of  the  appen- 
dix just  wliere  it  joins  the  caseum.  To  prevent  slipping,  two  safety  pins  are  passed 
through  each  side  of  the  appendix,  and  between  these  and  the  edges  of  the  wound 
sterile  gauze  pads  are  temporarily  inserted  to  prevent  infection,  and  over  this  is 
adjusted  an  ordinary  dressing.  Forty-eight  hours  later,  after  adhesions  have  oc- 
curred, the  appendix  is  clipped  off  near  the  level  of  the  skin  and  three  or  four 
linen  sutures  carried  through  the  entire  thickness  of  its  walls,  which  are  stitched 
to  the  margins  of  the  incision  through  the  skin,  thus  firmly  anchoring  it.  Into 
the  ca?cum  through  the  appendix  a  soft  velvet  drainage-tube  is  inserted.  In  amcebic 
dysentery  irrigations  with  solutions  of  quinia  have  been  successfully  employed. 
Normal  salt  solution  at  a  high  or  low  temperature,  as  indicated  by  tlie  character 
of  the  infection,  is  also  recommended.  In  catarrhal  dysentery,  with  or  without 
ulceration,  nitrate  of  silver  (1-5000)  and  one-half-of-one-per-cent  solutions  of 
ichthyol  have  given  satisfaction.  When  irrigation  is  no  longer  required,  the  tube 
should  be  removed  and  the  fistula  left  to  close  spontaneously. 

Flexure. — Not  infrequently  following  colitis,  a  localized  peritonitis  is  devel- 
oped, resulting  in  adhesions  with  more  or  less  contraction  of  the  new  connective 
tissue  which  is  a  part  of  the  process  of  repair  imder  septic  conditions,  causing 
partial  obstruction  of  the  lumen  of  the  gut  by  angulation  (Fig.  468).  While 
angulation  may  follow  the  healing  of  an  ulcer  or  a  local  peritonitis  at  any  point 
of  the  large  intestine,  it  is  almost  always  encountered  in  the  sigmoid  colon,  since 
these  septic  processes  are  nrore  frequently  located  here. 

The  symptoms  are  those  of  gradually  increasing  difficulty  in  emptying  the 
large  bowel.  These  patients  complain  of  constipation,  which  can  only  be  relieved 
by  high  irrigation.  Pain  is  not  usually  acute  in  character,  unless  a  quantity  of 
ingested  matter  accumulates  in  the  bowel  above  the  bend. 

The  diagnosis  depends  upon  a  carefvd  study  of  these  symptoms,  with  the  his- 
tory of  one  or  more  attacks  of  colitis.  With  the  patient  in  Tuttle's  position — i.  e., 
in  the  left  lateral  knee-chest  posture  on  Martin's  chair  (Fig.  469) — by  the  em- 
ployment of  this  surgeon's  pneumatic  electric  proctoscope  the  diagnosis  of  this 
anci  other  surgical  lesions  of  the  rectum  and  sigmoid  colon  may  be  made  positive. 

Treatment. — An  incision  should  l)e  made  over  the  seat  of  the  angulation, 
which  is  usually  in  the  left  iliac  fossa  and  is  practically  a  McBurney  incision 
upon  the  left  side.  By  separating  the  fibers  of  the  various  muscles  with  wide 
retraction,  sufficient  room  can  be  obtained  to  liberate  the  imprisoned  bowel  with- 
out a  resulting  ventral  hernia.  The  colon  should  be  carefully  separated  from  the 
adhesions,  and  the  raw  surface  so  made  covered  by  bringing  the  peritoneal  edges 


430 


FLEXURE  OF   THE  COLON 


together  willi  a  running  suture  of  ten-day  chromicized  catgut.  In  extreme  eases 
it  may  also  be  necessary  to  stitch  the  bowel  to  some  point  upon  the  abdominal 
wall  in  which  the  angulation  will  be  entirely  corrected.  If  stricture  has  resulted 
with  narrowing  of  the  canal  to  the  point  of  obstruction,  resection  and  end-to-end 
anastomosis  should  be  done. 

Ohslnictioti,  partial  or  complete,  of  the  large  intestine,  more  particularljf  of 
the  sigmoid  flexure,  as  a  result  of  diverticula,  has  been  considered  on  another  page. 


H.D-NiLes. 


Fig.  468. — Showing  commencing  ulcer  and  angulation  at  proximal  and  distal  ends  of  sigmoid.      (Niles.) 

Carcinoma  of  the  large  intestine,  especially  of  the  rectum  near  tlie  anus  and 
of  the  sigmoid  flexure  of  the  colon,  is  not  infrequent.  The  ileo-caseal  junction  is 
also  a  favorable  location  for  malignant  neoplasms.  A  large  proportion  of  cases 
of  cancer  of  the  intestinal  tract  are  found  below  the  ileo-caacal  valve,  and  men 
are  much  more  frequently  afEeeted  than  women. 

The  symptoms  are  those  of  gradually  increasing  obstruction,  in  which  pain 
is  not  a  marked  symptom,  until  the  narrowing  of  the  intestine  results  in  fecal 
accumulation  with  localized  colitis  and  possibly  peritonitis. 


RESECTION    OF  THE   RECTUM   AND  COLON 


431 


Later  a  tumor  may  be  recognized  by  careful  palpation.  The  passage  of  mucus 
and  blood  in  the  stools  of  patients  without  haemorrhoids  is  indicative  of  a  deeper 
and  more  serious  lesion. 

The  history  of  chronic  colitis  with  a  tendency  to  localization  should  attract  the 
attention  of  the  surgeon  in  the  effort  to  arrive  at  a  correct  diagnosis.     When  the 


Fig.  46!i. — PatirTit  in  knee-chest  posture  on  Martin's  chair.      (Tuttle.) 

carcinoma  is  at  or  near  the  anus,  its  recognition  by  inspection  and  digital  explora- 
tion is  not  difficult.  When  more  deeply  located,  examination  with  Tuttle's  procto- 
scope should  reveal  the  presence  of  a  neoplasm.  The  importance  of  the  early  recog- 
nition of  such  a  grave  disease  cannot  be  overestimated,  since  whatever  hope  the 
surgeon  may  hold  out  is  based  upon  early  oijerative  intervention. 

Treatment. — Early  and  complete  excision  of  that  part  of  the  alimentary  canal 
involved  in  the  disease  is  the  prime  indication  in  treatment.  Upon  the  first  sus- 
picion of  cancer,  an  exploratory  incision  should  be  made.  A  fair  proportion  of  these 
cases,  which  otherwise  are  inevitably  fatal,  would  be  saved  by  an  early  wide  excision, 
with  the  careful  removal  of  all  the  lymphatics  in  the  area  of  the  disease,  followed 
by  immediate  intestinal  anastomosis. 

The  definite  results  desired,  as  tersely  stated  by  Charles  H.  Mayo,^  are  perma- 
nent cure,  low  operative  mortality,  and  a  controllable  anus,  or  its  best  substitute. 
He  makes  a  clinical  division  of  cancers  of  the  lower  bowel  into  those  within  two 
and  one  half  inches  from  the  anus  and  those  which  lie  above  the  levator  ani  muscle. 

The  first  group  are  removable  by  incision  from  the  anal  region,  the  depth  and 
location  of  the  incision  being  determined  by  the  extent  of  the  bowel  to  be  excised. 
The  procedure  of  James  P.  Tuttle  is  preferred  (vide  Cancer  of  the  Eectum). 

With  the  higher  form  of  rectal  cancer  and  in  all  eases  of  carcinoma  of  the 
sigmoid,  the  double  operation  is  advised.  Mayo  gives  the  following  in  connection 
with  the  operation  of  choice  for  high  rectal  cancer : 

"  Bearing  in  mind  that  the  lymphatics  of  the  lower  rectum  first  pass  laterally 
with  the  middle  hsemorrhoidal  vessels  and  then  converge  posteriorly  in  the  meso- 
rectum  with  the  superior  rectal  artery,  it  is  evident  that  any  operation,  to  be 
effective,  must  remove  the  entire  chain  of  glands  with  all  the  fat  as  high  as  the 
promontory  of  the  sacrum. 

"The  method  of  procedure  is  as  follows:  The  patient  is  placed  in  the  high 
Trendelenburg  position  and  the  abdomen  freely  opened  in  the  middle  line.     The 

'  "Surg.,  Gyn.,  and  Obstetrics,"  page  4.     August,  1906. 


432  RESECTION  OF  THE   RECTUM  AND  COLON 

upper  limits  of  the  growth  and  its  relation  to  the  surrounding  tissues  are  noted. 
The  possibility  of  the  removal  of  all  of  the  obviously  infected  glands  is  ascertained, 
and  the  liver  examined  for  embolic  carcinoma.  If  the  case  is  a  favorable  one,  the 
intestines,  with  the  exception  of  the  sigmoid,  are  carefully  packed  away  with  large 
gauze  pads;  two  clamps  are  cauglit  across  the  lower  sigmoid  on  a  level  with  the 
promontory  of  the  sacrum  and  the  bowel  divided  between.  The  mesosigmoid  is 
liberated  by  lateral  incisions  and  the  proximal  fragment  brought  up  outside  of  the 
abdominal  wound.  A  ligature  is  thrown  around  the  bowel  immediately  below  the 
forceps,  which  are  removed  as  the  ligature  is  drawn  tight.  A  purse-string  suture 
is  placed  an  inch  below  the  end  of  the  stump,  which  is  invaginated  in  a  manner 
similar  to  that  of  the  appendix.  The  ends  of  the  ligature  are  left  long.  The 
threads  and  stump  are  carefully  cleansed.  The  distal  stiimp  is  treated  by  inversion 
in  a  similar  manner,  to  prevent  soiling.  Lateral  and  anterior  peritoneal  incisions 
are  now  made,  liberating  the  rectum  from  the  bladder  and  prostate  in  the  male 
and  from  the  uterus  in  the  female.  The  inferior  mesenteric  artery,  which  is  the 
upper  continuation  of  the  sui}erior  rectal,  is  caught  and  tied  above  and  to  the  left 
of  the  promontory  of  the  sacrum  at  as  high  a  point  as  can  be  safely  done  without 
interfering  with  the  nutrition  of  the  bowel  used  in  the  colostomy.  The  fat  is  care- 
fully separated,  the  entire  mass  of  gland-bearing  fascia,  with  the  fat,  is  wiped 
perfectly  clean  to  the  periosteum.  The  middle  sacral  artery  is  of  considerable  size 
in  most  cases,  and  should  be  caught  and  ligated  near  its  origin  from  the  abdominal 
aorta  between  the  common  iliac  vessels.  The  dissection  is  continued  downward, 
exposing  the  internal  iliac  vessels  and  the  ureters.  Most  of  this  can  be  done  by 
sponging.  The  middle  haemorrhoidal  vessels  are  caught  laterally,  as  they  come  olf 
with  the  inferior.  The  entire  area  is  now  packed  with  hot  moist  gauze,  and  the 
patient  put  in  the  perineal  position.  In  some  cases,  if  the  bowel  is  healthy  for  a 
space  of  four  inches  above*  the  anus,  it  is  clamped  and  ligated  at  this  point,  and 
cut  above  the  ligatures,  the  diseased  area  being  removed.  The  operator,  or  prefer- 
ably a  second  operator,  begins  the  lower  part.  A  pair  of  forceps  are  passed  into 
the  blind  pocket  of  bowel  from  below,  the  tied  end  of  the  bowel  is  pushed  into  the 
open  forcejDS,  and  they  are  withdrawn  through  the  anus,  inverting  the  bowel. 

"  After  cleansing,  the  thread  of  closure  is  cut,  and  the  forceps  are  now  passed 
through  the  invaginated  bowel  and  anus  into  the  pelvis  to  grasp  the  proximal  end 
of  bowel,  which  is  withdrawn,  and  the  two  ends  united  by  a  circular  end-to-end 
closure  outside  the  anus  and  allowed  to  retract.  Drainage  is  secured  by  a  midline 
incision  in  front  of  the  coccyx,  through  which  tube  drainage  into  the  pelvis  is  made. 
This  type  of  operation  (Mansill)  we  were  able  to  make  in  four  cases.  In  some 
colostomies,  the  lower  end  of  the  rectum  can  l)e  saved  as  a  blind  pouch,  or  tem- 
porarily employed  for  drainage  of  the  pelvis.  Should  the  disease  require  such 
extensive  removal  of  the  rectum  as  to  destroy  the  lower  rectal  wall  muscles  and 
nerves,  as  well  as  straighten  the  sigmoid  loop,  thereb}'  losing  both  retention  and 
control,  it  is  preferable  to  save  the  sigmoid  loop  as  such  and  make  an  abdominal 
anus.  To  employ  this  method,  a  small  gridiron  incision  is  made  on  the  left  side, 
as  would  be  done  on  the  opposite  side  for  appendicitis,  and  through  this  opening, 
using  the  ends  of  the  threads  as  a  tractor,  the  proximal  stump  is  pulled  out  three 
fourths  of  an  inch  beyond  the  skin  surface.  Three  or  four  linen  sutures  are  quickly 
placed,  uniting  the  Ijowel  to  the  peritona?um  on  the  inner  side,  and  a  silkworm-gut 
suture  on  the  outside  closes  each  angle  of  the  wound,  including  in  its  bite  the 
skin,  aponeurosis  of  the  external  oblique,  and  the  wall  of  the  bowel,  holding  it 
securely  in  position.  If  this  plan  is  followed,  the  operator  from  below,  after  insert- 
ing the  gauze  in  the  rectum  to  facilitate  subsequent  dissection,  and  closing  the 
anus  by  a  circular  suture,  circumscribes  the  anal  margin  with  a  deep  incision,  and 
dissects  the  perineal  portion  of  the  rectum  with  its  muscles  and  fat  free  from  the 
prostate  and  urethra,  or  from  the  vagina  in  women.  This  extends  up  to  the  levator 
ani  muscle,  which  forms  the  boundary  between  the  upper  and  lower  dissections. 
The  abdominal  operator  now  passes  down  the  fragment  of  lower  sigmoid  and  the 
upper  end  of  the  rectum  with  its  fat  and  glands  into  the  perineal  opening,  where 
they  are  removed  by  the  surgeon  working  below,  or  one  operator,  with  changes  of 
gloves,  can  accomplish  the  work  in  both  fields.    All  bleeding  points  are  caught  and 


COLOSTOMY  433 

lio-ated.  A  considerable  sized  gauze  drain  is  passed  from  above  downward,  leaving 
its  upper  end  just  exposed  on  a  level  with  the  peritonseum.  which  is  drawn  together 
to  cover  as  much  as  possible,  the  external  gauze  portion  being  brought  out  of  the 
perineal  wound.  The  sigmoid  loop  from  above  is  placed  over  the  exposed  surface, 
and  in  the  female  the  body  of  the  uterus  and  broad  ligaments  are  adjusted  with 
a  few  sutures  to  aid  in  covering.  The  upper  incision  is  completely  closed,  wliile 
the  perineal  opening  is  narrowed  to  proper  dimensions  for  drainage  by  a  few 
sutures. 

"  The  end  of  the  sigmoid  is  left  completely  obstructed  for  the  first  twentj'-four 
hours,  after  which  time  the  circular  suture  is  cut  and  the  stump  everted  by  the 
ligature,  which  is  tied  around  it,  and  the  bowel  opened. 

"  The  advantages  of  the  operation  herein  outlined  are  obvious.  The  disease 
is  removed  widely,  with  aU  of  its  tributary  lymphatics,  muscles,  and  related  tissues. 
The  anus  is  placed  in  a  position  easy  of  inspection  and  cleansing ;  the  sigmoid  trap 
obviates  the  necessity  of  frequent  stools,  and  the  intermuscular  incision  gives  a  fair 
degree  of  control." 

Artificial  Anus. — ^Unfortunately,  in  a  large  proportion  of  cases  of  malignant 
disease  of  the  lower  bowel  which  come  to  the  notice  of  the  surgeon,  operative  treat- 
ment has  been  so  long  delayed  that  a  cure  is  impossible,  and  nothing  remains  but 
to  give  the  greatest  possible  relief  to  the  patient. 

The  establishment  of  a  fecal  fistula  between  the  colon  and  the  abdominal  wall 
— colostomy — is  usually  performed  in  the  lower  part  of  the  descending  colon,  or  in 
the  sigmoid  flexure.  It  is  indicated  as  a  palliative  measure  in  occlusion  of  the 
alimentary  canal  on  the  anal  side  of  the  operation  by  stricture,  neoplasms,  intussus- 
ception, volvulus,  or  any  lesions  for  the  relief  of  which  exsection  or  lateral  anas- 
tomosis is  not  permissible.  In  chronic  colitis  or  practitis  it  is  a  curative  operation, 
in  giving  complete  rest  to  the  bowels  until  recovery  ensues. 

It  is  not  so  frequently  performed  now  as  formerly.^  Many  of  the  lesions  for 
which  it  was  done  are  now  cured  by  resection  of  the  intestine  involved.  Fecal 
fistula  is  attended  with  so  much  discomfort  that  a  very  considerable  risk  is  justified 
in  the  performance  of  a  radical  operation  in  the  hope  of  avoiding  the  annoyance 
of  a  constant  discharge  from  an  opening  in  the  large  intestine. 

At  a  point  aljout  one  inch  above  and  one  and  one  half  inch  inside  of  the  anterior 
superior  spine  of  the  left  ileum  an  incision  about  three  inches  long  is  made  through 
the  skin  obliquely  downward  and  parallel  to  the  fibers  of  the  external  oblique 
muscle.  These  fibers  and  those  of  the  mtiscle  in  each  layer  are  separated  by  bltmt 
scissors  and  held  apart  by  retractors  until  the  peritonteum  is  clearly  seen.  All 
hemorrhage  should  be  arrested,  and  an  incision  about  two  inches  long  made  through 
the  peritonaeum  in  the  same  general  direction  as  the  superficial  wound.  The  edges 
of  the  peritona?itm  should  be  firmly  held  by  forceps,  or  better  by  two  silk  loops 
passed  from  within  outward  through  the  peritonaeum  and  the  entire  thicloiess  of 
the  abdominal  wall,  and  tied  in  a  long  loop,  serving  a  double  purpose  as  a  retractor, 
and  also  to  prevent  the  peritonaeum  from  being  stripped  from  the  abdominal  wall 
during  the  examination  or  operation.  The  patient  should  now  be  placed  in  the 
Trendelenburg  posture,  and  the  incision  enlarged,  if  necessary  to  permit  the  intro- 
duction of  more  than  one  or  two  fingers,  in  order  to  insure  a  thorough  examina- 
tion. The  sigmoid  flexure  and  colon  are  easily  recognized  not  only  by  the  longi- 
tudinal muscular  bands,  but  by  the  beads  of  fat  (epiploiccE)  which  are  attached 
along  the  border  opposite  the  mesentery.  If  the  artificial  anus  to  be  established  is 
only  a  temporary  expedient,  the  teclmic  differs  in  an  essential  feature  from  that 

1  The  old  operation  of  lumbar  colostomy  on  either  the  right  or  the  left  side  is  now  practically 
abandoned.  Left  lumbar  colostomy  was  done  through  a  perpendicular  incision  in  front  of  the 
left  quadratus  lumbormn  muscle  or  by  an  oblique  incision  just  below  the  floating  rib.  The  muscles 
were  divided  or  separated  by  blunt  dissection  until  the  colon  was  reached.  This  was  seized  by 
forceps  and  pulled  into  the  wound  far  enough  to  permit  the  insertion  of  two  silk  ligatures  through 
the  skin  at  the  edge  of  the  wound,  then  through  the  intestine  embracing  about  one  third  of  its 
circumference  and  out  through  the  integument  on  the  opposite  side.  The  intestine  is  now  incised 
longitudinally,  and  the  loops  of  the  two  sutures  pulled  out  through  this  incision.  di\ided  in  the 
middle  at  each  end,  and  tied  so  as  to  fasten  the  wall  of  the  bowel  to  the  edge  of  the  skin,  and  ad- 
ditional sutures  were  inserted  on  either  side  to  thoroughly  anchor  the  gut  in  its  new  position. 


434 


COLOSTOMY 


in  whicli  a  permanent  opening  is  to  be  established.  For  temporary  colostomy/  as 
soon  as  the  sigmoid  is  drawn  up  and  the  point  to  be  opened  is  selected,  a  small 
opening  is  made  through  the  mesentery,  avoiding  the  blood  vessel,  and  a  glass  rod 
about  one  quarter  of  an  inch  thick  by  four  inches  long  is  passed  through  this,  its 


'\ 

1 

^         ( 

T^^ 

r--V 

\ 
\ 

Fig.  469a. — Temporary  inguinal  colostomy.     Gut  supported  on  rod  and  sutures  in  position.     (Tuttle.) 

ends  resting  upon  either  side  of  the  wound.  "  The  lower  angle  of  the  wound  is 
closed  by  silkworm-gut  sutures  passed  through  the  abdominal  wall  until  the  lower 
limb  of  the  intestinal  loop  is  pressed  against  the  glass  rod.  Fine  continuous  catgut 
sutures  are  now  passed  at  the  two  angles  of  the  wound  through  the  skin  and  peri- 


FiG.  4696. — Incision  for  opening  tlie  gut  in  temporary  inguinal  colostomy.     (Tuttle.) 

tonseum,   then   through   the   muscular   wall   of   the   gut,   and   again  through   the 

peritouEeum  and  skin  upon  the  opposite  side  (Fig.  469a).     Small  sterile  pads  are 

placed  under  the  ends  of  the  glass  rod  and  along  the  edges  of  the  wound  close 

>  Prof.  James  P.  Tuttle. 


COLOSTOMY  435 

to  the  intestine.  The  projecting  loop  of  gut  and  the  entire  wound  is  covered  witli 
protective  tissue;  over  tliis  gauze,  adhesive  strips,  and  a  firm  abdominal  bandage. 
The  gut  is  not  opened,  but  if  there  is  great  distention  by  gas  a  trocar  may  be 
inserted  to  permit  its  escape  and  the  opening  closed  by  Lembert  sutures.  The 
patient  is  placed  in  bed,  hips  well  elevated,  is  given  sufficient  morphia  to  control 
vomiting  and  quiet  the  peritonasum  for  ten  or  twelve  hours.  After  six  hours  the 
intestine  may  be  incised,  but  it  is  preferal:ile  to  wait  for  two  or  three  days  in  order 
to  secure  firm  adhesions.  The  opening  should  be  made  through  the  longitudinal 
band  opposite  the  mesentery,  and  should  extend  from  the  upper  angle  of  the  wound 
to  one  half  inch  below  the  glass  rod.  A  transverse  incision  is  then  made  at  the 
lower  end  involving  two  tliirds  of  the  circumference  of  the  gut  (Fig.  4696).  The 
straight  flap  in  the  lower  segment  falls  do^vnward  like  a  trapdoor,  practically 
closing  the  lower  aperture,  while  the  triangular  flaps  are  naturally  retracted  out- 
ward. When  the  fistulous  opening  shall  have  served  its  purpose  by  simply  suturing 
the  edges  of  this  T-shaped  incision  together  without  opening  the  peritoneal  cavity, 
the  integrity  of  the  intestinal  wall  is  restored.  During  the  existence  of  the  fistula, 
if  it  should  at  any  time  be  deemed  necessary  to  irrigate  that  part  of  the  intestinal 
tract  between  the  opening  and  the  anus,  the  lower  transverse  flap  can  be  raised 
and  the  irrigating  tube  inserted.  It  is  important  to  bear  in  mind  the  necessity  of 
making  the  artificial  anus  as  high  up  in  the  sigmoid  as  possible  when  a  resection 
is  to  be  made  below.  The  longer  the  loop  left  below  the  artificial  anus  the  easier 
the  subsequent  procedure.  The  glass  rod  is  retained  in  position  for  two  or  three 
weeks,  and  should  be  prevented  from  slipping  out  of  place  by  adhesive  plaster 
properly  arranged.  Should  it  become  necessary  to  convert  the  temporary  artificial 
anus  into  a  permanent  one,  this  can  be  accomplished  by  trimming  oil  the  projecting 
bowel  wall  to  near  the  level  of  the  skin."  Since  the  colon  is  not  sensitive,  these 
incisions  may  be  made  without  an  antesthetic. 

When  a  permanent  artificial  anus  is  to  be  established,  the  procedure  of  Prof. 
James  P.  Tuttle  ^  should  be  selected. 

"  The  operation  is  begun  by  the  ordinary  incision  for  inguinal  colotomy.  The 
fibers  of  the  external  and  internal  oblique  muscles  are  separated  by  a  blunt  instru- 
ment instead  of  being  cut.  The  transversalis  fascia  and  peritonaeum  are  incised 
in  a  line  parallel  to  Poupart's  ligament.  A  loop  of  sigmoid  sufficiently  long  to 
be  drawn  at  least  two  inches  outside  of  the  abdominal  cavity  is  selected,  and  a 
tape  or  loop  of  large  silk  is  passed  around  it  through  a  small  slit  in  the  mesentery, 
the  ends  being  left  long  and  held  by  an  artery  forceps.  The  lower  fibers  of  the 
external  oblique  are  then  pulled  downward,  and  the  internal  oblique  is  split  laterally 
to  the  distance  of  about  two  centimeters  (three  quarters  of  an  inch).  A  canal  is 
then  made  between  the  skin  and  the  external  oblique  downward  to  the  extent  of 
about  two  inches,  opening  through  an  incision  in  the  skin  just  above  Poupart's 
ligament  (Fig.  470).  This  canal  and  incision  should  be  large  enough  to  admit 
of  the  loop  of  sigmoid  being  drawn  through  them  without  much  compression.  With 
the  aid  of  the  dressing  forceps  the  knuckle  of  gut  is  then  dragged  through  the 
lateral  slit  in  the  internal  oblique  and  do^vnward  through  the  canal  outside  of  the 
external  oblique  muscle  until  it  emerges  at  the  inferior  opening  in  the  skin.  It 
is  held  in  this  position  either  by  the  passage  of  a  glass  rod  through  the  opening 
in  the  mesentery,  or  by  suturing  it  to  the  edges  of  the  skin  wound.  The  abdominal 
wound  is  then  closed  by  chromicized  catgut  sutures  in  the  muscular  layers  and  a 
subcutaneous  silk  suture  in  the  skin;  it  is  then  sealed  by  iodoformized  collodion 
and  dressed  with  sterilized  gauze,  over  which  a  layer  of  rubber  protective  tissue  is 
placed,  and  sealed  to  the  skin  with  chloroform.  This  latter  precaution  is  taken 
to  avoid  infection  of  the  primary  wound  through  the  escape  of  fsces  when  the 
gut  is  opened.  If  necessary,  the  loop  of  intestine  may  be  opened  immediately,  but 
ordinarily  it  is  better  to  wait  twenty-four  to  forty-eight  hours  before  doing  so. 
This  is  accomplished  by  a  simple  slit  in  the  line  of  the  longitudinal  fibers  of  the 
gut.    After  ten  days  or  more,  the  protruding  portions  of  the  gut  should  be  trimmed 

»  This  operation  together  with  the  technic  of  that  just  given  are  credited  to  Prof.  James  P. 
Tuttle.  "A  Treatise  on  Diseases  of  the  Anus,  Rectum,  and  Pelvic  Colon,"  by  James  P.  Tuttle, 
A.M.,  M.D.,  D.  Appleton  and  Company,  1902. 


436 


COLOSTOMY 


down  flush  with  the  skin  and  the  artificial  anus  will  present  itself  as  a  double- 
barreled  aperture,  one  opening  of  which  connects  with  the  proximal  and  the  other 
with  the  distal  end  of  the  sigmoid  (Fig.  471).  The  gut  is  brought  outside  of  the 
external  oblique  muscle  in  order  that  it  will  rest  upon  a  resisting  plane,  and  a 
truss  or  compress  can  be  placed  upon  it,  thus  absolutely  occluding  its  caliber. 
Being  passed  through  the  slit  in  the  external  oblique,  it  is  surrounded  by  muscular 
fibers,  and  thus  obtains  a  certain  amount  of  voluntary  control.  In  the  majority 
of  cases  no  compressing  apparatus  is  necessary,  as  the  patient  usually  possesses 
almost  complete  continence  without  it.  When  it  is  necessary,  an  ordinary  single 
spring  hernial  truss  with  an  elongated  pad  placed  somewhat  outside  of  the  usual 
position  serves  every  purpose.  Not  only  is  the  continence  obtained  by  this  method 
exceedingly  satisfactory,  but  the  site  of  the  anus  is  very  convenient  for  the  patient. 


Fig.  470. — Permanent  colostomy     (Tuttle's  method).     The  gut  being  dragged  through  the  spHt  inter- 
nal oblique  and  then  througli  the  subcutaneous  canal. 

He  can  sit  upon  an  ordinary  toilet-seat  with  a  pus  basin  held  underneath  the  arti- 
ficial anus  and  relieve  his  bowels  with  as  little  inconvenience  as  if  the  anus  were 
in  the  normal  position.  The  parts  can  be  easily  cleaned,  and  in  the  cases  thus  far 
observed  there  has  never  been  the  slightest  tendency  toward  prolapse.  The  inferior 
segment  of  the  sigmoid  can  also  be  washed  out  and  irrigated  through  this  type  of 
permanent  artificial  anus,  thus  obviating  the  danger  of  collections  of  pus  and  putre- 
fying substances  in  this  portion  of  the  gut." 

While  the  operations  advised  by  Tuttle  both  for  a  permanent  and  temporary 
colostomy  are  preferable,  should  the  conditions  be  such  as  to  render  these  pro- 
cedures difficult  of  execution,  the  following  simple  operation  of  Prof.  J.  A.  Bodine 
is  well  adapted  for  securing  a  temporary  fistula,  and  for  restoring  the  lumen  of  the 
gut  when  the  artificial  anus  is  no  longer  required. 

When  the  eontinitity  of  the  intestine  is  to  be  restored,  of  course  the  mesentery 
is  excluded  from  between  the  two  approximating  rows  of  sutures.  Later,  when 
these  walls  have  become  agglutinated  by  inflammatory  adhesions,  the  gut  is  divided 


COLOSTOMY 


437 


■vrithout  interfering  vriih  the  blood  supply.  The  method  is  as  follows:  As  soon  as 
the  proper  incision  through  the  peritona?um  is  made,  a  sterile  pad  is  introduced 
■while  the  operator  stitches  the  parietal  peritonreum  to  the  integument  with  a  con- 
tinuous catgut  suture.     If  there  be  a  tumor,  stricture,  or  necrotic  focus  upon  the 


Fig.  471. — Permanent  colostomj-  completed  by  Tuttle's  method. 

intestiae,  it  is  brought  out  through  the  wound  until  sis  inches  of  healthy  intestine 
on  each  side  of  the  part  to  be  excised  are  exposed.  The  two  limbs  of  the  loop,  with 
the  lesion  at  the  apex  of  the  knuckle,  are  laid  side  by  side,  and  a  running  stitch 
of  tine  silk,  beginning  at  the  point  where  tlie  exsection  is  desired,  is  carefully 
inserted,  uniting  the  two  pieces  of  intestine  close  to  and  parallel  with  the  mesen- 
teric border  for  six  inches  (Fig.  4T2).  If  the  fistula  is  to  be  permanent,  the 
mesenteric  attachment  is  half-way  between  the  two  rows  of  sutures.  If  temporar)% 
the  loops  are  approximated,  leaving  the  mesentery  free.  There  should  be  alx)ut 
an  iaeh  of  space  between  the  two  rows  of  sutures.  At  the  deepest  portion  of  the 
approximation — that  is,  the  portion  most  remote  from  the  part  to  be  excised — the 
sutures  should  be  inserted  across  the  bowel  so  as  to  insure  a  complete  approximation 
at  this  point  and  prevent  any  possibility  of  leakage  into  the  peritoneal  cavity  after 
the  septum  has  been  divided.  The  row  of  sutures  should  represent  an  elongated  U. 
The  sutured  loop  is  then  passed  back  into  the  abdomen  until  the  point  where  the 
intestine  is  to  be  excised  is  on  a  level  with  the  skin  surface,  and  it  is  here  stitched 
into  the  margin  of  the  abdominal  wound  with  a  continuous  suture  of  strong  catgut 
If  the  excision  is  to  take  place  at  once,  as  in  cases  where  a  fistulous  opening  is 
urgent  for  the  patienf  s  safety,  this  last  suture  should  be  of  silk,  but  as  peritoneal 
surfaces  are  brought  tosether,  if  the  opening  can  be  left  for  twenty-four  or  thirty- 
six  hours,  adhesions  will  have  formed  in  that  time  and  catgut  may  be  employed. 
Silk  is,  however,  in  my  opinion,  the  safest  suture.  If  waiting  is  permissible  after 
twelve,  twenty-four,  or  thirty-six  hours,  cocaine  anaesthesia  (two-per-cent  solution) 
may,  if  necessary,  be  employed,  and  the  protruding  intestine  snipped  off  with  scis- 
sors on  a  level  with  the  skin.    After  one  or  two  weeks,  or  a  longer  period,  if  this 


438 


FECAL   FISTULA 


be  required,  the  septum  between  the  two  rows  of  sutures  maj^  be  divided  by  Grant's 
enterotome  ( Fig.  473 )  or  a  pair  of  straight  scissors,  introducing  one  blade  into 
the  upper  and  the  otlier  into  the  lower  bowel  channel,  guiding  the  blades  back  by 
means  of  the  finger,  to  the  middle  line  between  the  two  rows  of  sutures  and  cutting 
to  the  required  depth.  The  passage  of  the  fecal  current  prevents  reunion  of  the 
divided  septum,  and  in  the  course  of  time  the  fecal  fistula  closes  by  granulation. 
The  same  procedure  would  be  advisable  after  strangulated  hernia  with  necrosis 
of  the  intestine,  where  end-to-end  anastomosis  by  direct  suture  is  not  permissible. 


Fig.  472. — Prof.  J.  A.  Bodine's  operation  for  lateral       Fig.  473. — Intestinal  anastomosis.  Showing  the 

anastomosis,  with ultimaterestorationofthecon-  septum  to  be  divided   in   restoring  the  fecal 

tinuitv  of  the  canal,  showing  one  side  of  the  loop  current.       Grant's    clamp     in     po-sition     for 

after  it  has  been  sutured,  passed  back  into  the  the  division.      In  permanent  colostomy  this 

cavity,  and  stitched  into  the  abdominal  wound.  septum    remains    as    a    rigid    and    effective 

The  lesion  is  left  protruding,  and  tlie  dotted  line  spur, 
indicates  where  the  protrusion  is  to  be  clipped  off. 

Fecal  Fistula. — A  fecal  fistula  may  exist  between  any  portion  of  the  intestinal 
canal  and  the  exterior  through  the  integument;  from  the  intestine  into  a  normal 
cavity,  as  the  bladder  or  uterus,  and  thence  to  the  exterior ;  into  an  abnormal  cavity, 
as  an  abscess,  and  thence  out  through  one  of  the  hollow  organs  or"  directly  to  the 
skin;  or  it  may  lead  into  a  cul-de-sac  or  blind  pocket. 

Fecal  fistulffi  are  congenital  and  acquired. 

Imperforate  anus  is  the  most  frequent  cause  of  congenital  fistula.  The  pressure 
of  accumulated  matter  at  the  extremity  of  the  canal  induces  inflammation,  ulcera- 
tion, and  perforation,  with  extravasation  of  the  bowel  contents.  If  the  congenital 
obstruction  is  low  down,  the  opening  may  occur  through  the  perineum,  bladder,  or 
vagina.  If  higher  up,  the  fistula  may  open  through  the  abdominal  wall  at  the 
umbilicus,  or  below  this  point  in  the  linea  alba,  or  posteriorly  near  the  spine.  A 
rare  cause  of  congenital  fistula  is  the  presence  of  the  omphalo-mesenteric  duct,  or 
Meckel's  diverticulum,  which,  as  heretofore  stated,  opens  at  the  umbilicus. 

Acquired  fecal  fistulfe  may  be  surgical  or  accidental.  Colostomy  and  enteros- 
tomy are  examples  of  the  former,  while  the  latter  result  from  perforating  wounds 
of  the  intestinal  canal,  either  from  the  exterior,  as  by  gunshot  or  punctured  wounds, 
or  by  the  passage  of  some  ingested  sharp  or  hard  body  through  the  intestinal  wall ; 
or  by  perforation  of  the  intestine  by  an  ulcer  or  abscess,  or  from  gangrene  due  to 
strangulation,  contusion,  etc. 


FECAL   FISTULA  439 

The  diagnosis  of  a  fecal  fistula  which  communicates  directly  with  the  exterior 
is  made  evident  by  the  escape  of  gas  and  ingested  matter.  Indirect  fistulfe  can  also 
be  determined  by  the  careful  examination  of  the  discharges  from  the  organs  through 
which  they  pass.  In  a  case  reported  by  Dr.  Ivrackowitzer,  in  the  "  Transactions 
of  the  New  York  Pathological  Society/"'  an  ulcer  of  the  appendix  vermiformis  had 
opened  into  the  bladder.  The  diagnosis  of  entero-vesical  fistula  was  established 
by  the  escape  of  a  lumbricoid  worm  from  the  urethra.  Blind  fistulte  cannot  often 
be  made  out  until  demonstrated  by  e3:p)loration. 

In  determining  into  what  portion  of  the  intestinal  canal  the  fistula  opens  one 
must  consider,  first,  the  character  of  the  discharge;  second,  the  distance  from  the 
rectum,  as  determined  by  injections. 

In  congenital  fistiilce  opening  into  the  perinsum  the  inference  is  natural  and 
generally  correct  that  the  lower  portion  of  the  large  intestine  is  involved.  If  bile 
is  freelj^  discharged  through  a  congenital  or  acquired  fistula,  it  is  safe  to  conclude 
that  the  opening  is  not  very  far  removed  from  the  duodenum  or  upper  portion  of 
the  jejunum.  The  odor  of  gas  or  ingesta  escaping  from  the  large  intestine  is 
usually  more  offensive  than  that  from  the  small  bowel. 

When  caused  by  a  wound,  the  known  direction  and  character  of  the  penetrating 
body  will  aid  in  arriving  at  a  correct  idea  of  the  gut  penetrated. 

A  fistula  resulting  from  appendicular  or  perityphlitic  abscess  occurs  almost 
always  in  the  ctecum.  more  rarely  in  the  lower  portion  of  the  ascending  colon  or 
lower  ileum.  When  the  colon  is  involved  the  location  may  be  determined  by  slowly 
injecting  milk  per  rectum,  having  measured  the  quantity  injected  until  it  begins 
to  flow  out  at  the  external  opening. 

The  prognosis  of  fecal  fistula  depends  upon  its  character.  Congenital  fistulse 
are  obstinate  under  treatment.  Acciuired  fistulse  may  be  cured  in  the  majority  of 
instances. 

Treatment. — Congenital  fistulas,  resulting  from  imperforate  anus,  can  be  healed 
by  the  establishment  of  an  opening  in  the  perinaeum  which  shall  communicate  with 
the  most  dependent  portion  of  the  blind  gut.  When  this  is  done,  a  pad  worn  over 
the  fistulous  opening  will  lead  to  its  gradual  occlusion.  When  the  fistula  is  the 
result  of  a  patulous  omphalo-mesenteric  canal,  it  may  be  closed  by  sutures  or  by 
a  compress. 

Acquired  fistulse  not  infrequently  heal  spontaneously.  The  operation  consists  in 
cutting  down  upon  the  opening  in  the  gut  and  laying  freely  open  all  sinuses  which 
communicate  with  the  fistulous  outlet.  As  the  track  of  the  fistula  is  often  tortuous, 
it  is  at  times  exceedingly  difficult  to  follow  it.  A  repetition  of  the  method  employed 
in  the  following  case  will  be  of  service  in  the  more  complicated  operations: 

In  1880  a  young  man  came  under  my  observation  on  account  of  a  pistol-shot 
wound.  The  ball  had  entered  the  abdomen  on  a  level  with  and  about  one  and  a 
half  inch  to  the  inner  side  of  the  left  anterior  superior  spine  of  the  ilium.  From 
the  direction  in  which  the  weapon  was  aimed,  the  missile  was  thought  to  have 
passed  directly  back  and  lodged  in  the  iliac  fossa.  There  were  no  immediate  symp- 
toms of  perforation  of  the  intestine.  An  abscess  formed  which  discharged  from 
the  wound  of  entrance,  and,  about  six  weeks  after  the  receipt  of  the  injury,  a 
fecal  fistula  was  established.  The  fistulous  track  was  so  long  and  tortuous  that 
it  could  not  be  followed.  After  the  anesthesia  was  complete,  warm  milk  was 
thrown  into  the  bowel  until  it  ran  out  at  the  oj^ening.  The  stream  of  milk  was 
then  followed  without  difficulty,  and  the  opening  discovered.  All  communicating 
sinuses  were  laid  open  and  packed  with  gauze.  The  wound  closed  within  a  month, 
and  the  patient  was  cured. 

It  will  be  advisable,  in  attempting  to  close  the  fistula,  for  the  patient  to  maintain 
a  position  which  will  prevent  the  gravitation  of  ingested  matter  into  the  opening. 

Closure  of  the  external  orifice  by  means  of  sutures  is  not  advisable,  since  it 
may  induce  fecal  infiltration.  A  recovery  is  usually  hastened  when  the  margins 
of  the  wound  in  the  integument  can  be  stitched  to  the  edges  of  the  opening  into 
the  bowel,  as  directed  in  enterostomy. 

In  persistent  fistula  of  the  ctecum  as  met  with  after  appendicitis  a  lateral  anas- 
tomosis between  the  small  intestine  and  colon  will  effect  a  cure. 


CHAPTER    XXIV 

appendicitis/    PEPiITONITIS 

Appendicitis  is  an  inflammation  of  the  vermiform  appendix,  through  the  dis- 
eased or  perforated  wall  of  which  septic  organisms  penetrate,  producing  local  or 
general  peritonitis. 

The  appendix  comes  off  from  the  inner  jaosterior  portion  of  the  CEecum  at  its 
lower  end,  where  the  three  longitudinal  muscular  bands  of  tlie  colon  unite.  It  is 
held  in  position  usuall_y  by  a  small  fold  of  peritonffium,  which  forms  its  mesentery 
(meso-appendix).  It  communicates  with  the  csecum  by  a  small  opening,  which  is 
partly  guarded  by  a  valvelike  fold  of  mucous  membrane.  The  average  length  of 
this  organ  is  about  three  inches,  but  it  may  vary  from  one  to  nine  inches.  The 
diameter  of  the  lumen  varies  from  one  eighth  to  one  quarter  of  an  inch,  occasion- 
ally larger.  Of  one  hundred  and  forty-four  dissections  by  Prof.  Joseph  D.  Bryant, 
in  thirty-four  its  direction  was  inward;  in  thirty-two  it  was  inward  and  behind 
the  caecum;  in  twenty-eight  it  pointed  inward  and  slightly  downivard;  in  twenty- 
one,  doivnivard  into  the  pelvis;  directly  downward  and  inivard  in  nine;  upward 
and  tachivard  in  three;  upward  and  outward  in  two. 

The  meso-appendix  does  not  always  entirely  cover  this  organ  with  peritonsenm, 
at  times  leaving  a  strip  upon  the  posterior  aspect,  which,  in  common  witli  that 
portion  of  the  ctecum  may  be  uncovered  and  in  contact  with  the  iliac  fascia.  Be- 
neath the  peritoneal  covering  is  a  thin  layer  of  longitudinal  muscular  fibers;  then 
a  layer  of  circular  muscular  fibers,  a  submucous  layer,  and  a  thick  mucous  mem- 
brane which  is  studded  with  closed  follicles  and  lined  with  C3dindrical  epithelia. 
The  chief  source  of  blood  supply  is  a  branch  which  arises  from  a  loop  of  the 
colica  media.  This  vessel  runs  along  the  border  of  the  meso-appendix,  giving 
off  branches,  which  pass  to  the  organ.  When  the  meso-appendix  is  wanting  the 
artery  runs  directly  along  the  peritoneal  covering  of  the  appendix.  Probably  it  is 
in  these  cases  of  limited  single  arterial  supply  that  rapid  gangrene  occurs,  the  ulcer 
or  primary  focus  of  infection  suddenly  occluding  this  vessel. 

Anatomically  the  appendix  occupies  an  unfortunate  position.  It  is  subjected, 
to  distention  from  semiliquid  ingesta,  which  enter  it  from  the  crecum  by  gravitation. 
On  account  of  muscular  insufficiency  it  is  unable  to  empty  itself,  and  the  resulting 
decomposition  of  its  contents  make  of  it  even  more  than  the  blind  gut  from  which 
it  sjDrings  a  breeding-ground  for  septic  organisms.  In  addition  to  overdistention, 
the  weight  of  the  loaded  eascum,  tvith  the  strong  reverse  peristalsis  of  the  ascending 
colon,  tends  to  interfere  with  the  proper  blood  supply  to  its  walls. 

'  Kroenlein  in  1884  did  the  first  appendectomy,  placing  a  double  ligature  (material  not  stated) 
on  the  base  of  the  appendix,  which  was  removed,  with  fatal  result  ("  Archiv  f.  klin.  Chir.,"  p.  516, 
1886).  Dr.  W.  W.  Grant  placed  a  ligature  upon  and  cut  off  but  did  not  remove  the  appendix  for 
appendicitis  in  1885.  The  patient  recovered.  Dr.  Reginald  H.  Fitz,  of  Boston,  in  1886  pubhshed 
his  classical  article  upon  this  subject.  The  late  Dr.  Richard  Hall,  of  New  York,  in  May,  1886, 
did  a  successful  appendectomy,  ligating  the  stump  with  a  catgut  ligature.  The  late  Prof.  T.  G. 
Morton,  of  Philadelphia,  operated  upon  the  first  case  for  which  the  diagnosis  had  been  made 
and  operation  done  with  the  intention  of  removing  the  appendix.  The  stump  was  tied  with  a 
silk  ligature,  and  the  patient  recovered.  Dr.  Simon  Baruch,  of  New  York  City,  in  1887,  after  an 
experience  based  upon  post-mortem  examinations,  diagnosticated  appendicitis  in  a  boy  eleven  years 
of  age,  and  succeeded  after  much  insistence  in  persuading  the  late  Dr.  Henry  B.  Sands  to  operate 
directly  for  this  disease.  This  patient  recovered.  Dr.  Charles  McBurney's  name  is  associated 
with  one  of  the  surgical  approaches  to  this  organ,  and  Dr.  John  B.  Deaver,  of  Philadelphia,  has 
demonstrated  the  great  advantage  of  the  route  through  the  right  rectus  muscle,  the  "Deaver 
incision." 

440 


APPENDICITIS,   PERITONITIS  441 

Appendicitis  occurs  more  frequently  in  males  than  in  females  (four  to  one), 
and  about  one  half  of  all  cases  are  under  twenty-five  years  of  age.  Dr.  J.  F. 
Erdmann  reported  sixty  cases  in  children — twenty-five  under  two  years,  the  young- 
est eleven  months.^  With  adults,  those  who  ingest  large  quantities  of  food 
and  lead  sedentary  lives  are  more  frequently  attacked.  As  shown  by  Dr.  H.  A. 
Royster,  under  the  same  conditions  of  living  appendicitis  is  as  common  with 
negroes  as  whites."  It  is  rarely  caused  by  fruit  seeds  or  foreign  bodies.  Small 
fecal  accretions  (enteroliths)  are  not  infrequently  present,  and  are  doubtless  etio- 
logical factors.  There  are  a  few  cases  on  record  in  which  a  blow  upon  the  abdomen 
directly  over  the  organ  was  the  immediate  exciting  cause.^  Tubercular  deposits 
(bacilli  tuberculosis)  are  only  in  very  exceptional  instances  to  be  accepted  in  the 
etiolog}'  of  this  disease. 

The  frequency  of  the  infection  of  this  organ  may  be  accounted  for  by  its  low 
resistance  due  to  interference  with  its  blood  supply ;  by  the  constant  presence  within 
its  cavity  of  shoals  of  pathogenic  bacteria,  and  by  the  more  or  less  persistent  over- 
distention  with  liquid,  semisolid,  or  solid  ingesta  and  the  gaseous  products  of 
decomposition  which  its  degenerate  muscle  cannot  expel.  Any  breach  in  the  endo- 
thelia  lining  the  wall  is  an  open  door  through  which  enter  the  ever-present  organ- 
isms of  disease. 

Appendicitis  may  be  considered  clinically  under  the  following  heads:  Subacute, 
Acute,  Chronic. 

In  the  subacute  variety  the  infection  is  mild,  and  usually  limited  to  a  small 
area  of  the  mucous  membrane.  Should  the  area  of  infection  become  larger  and 
involve  the  submucous  and  muscular  layers  and  peritoneal  covering,  with  or  without 
perforation,  it  passes  into  the  acute  form.  Perforation  or  gangrene,  with  rapidly 
developing  peritonitis,  local  or  general,  are  forms  of  acute  appendicitis. 

Chronic  appendicitis  is  practically  nothing  more  than  repeated  attacks  of  the 
subacute  variety,  with  intervening  periods  of  more  or  less  complete  absence  of 
inflammation.  It  has  been  called  relapsing  or  recurring  or  "  interval "  -  appen- 
■  dicitis. 

Symptoms. — Pain  is  the  first  symptom  in  practically  all  forms  of  appendicitis. 
In  the  subacute  variety,  and  in  the  early  stages  of  an  acute  attack,  it  may  be 
mild  in  character.  In  the  more  rapidly  developing  cases  it  is  apt  to  be  severe 
and  persistent.  In  the  earlier  stages  it  is  often  referred  to  the  region  of  the 
navel,  and  later  to  the  exact  location  of  infection.  If,  however,  direct  and  deep 
pressure  with  the  end  of  a  single  finger  be  made  at  McBurney's  point,  the  sharp 
sense  of  pain  elicited  will  determine  this  to  be  the  seat  of  inflammation.  This 
point  is  from  one  half  to  one  inch  below  the  center  of  a  line  drawn  from  the 
anterior  superior  spine  of  the  ilium  to  the  umbilicus. 

jSTausea,  with  or  without  vomiting,  is  a  frequent  early  symptom  of  appendicitis, 
and  in  general  suggests  an  acute  attack.  Eigidity  of  the  muscles  directly  over  the 
organ  is  one  of  the  most  unerring  symptoms  of  peritonitis  from  disease  of  the 
appendix.  With  a  patient  resting  upon  the  back,  if  the  hand  be  gentl}^  drawn 
across  the  abdomen  from  the  left  iliac  spine  to  the  right,  the  comparative  rigidity 
of  the  muscles  over  the  appendix  will  be  appreciated.  This  muscular  resistance  is 
at  times  so  strong  and  so  sharply  defined  as  to  be  mistaken  for  a  peri-appendicular 
exudate  or  abscess.  In  very  young  children,  in  addition  to  overlying  muscular 
rigidity  the  patient's  hand  will  instinctively  ward  off  the  hand  of  the  surgeon 
(Erdmann).  In  the  diagnosis,  a  careful  comparison  with  the  symptoms  of 
intussuscej)tion,  gastro-enteritis,  entero-colitis,  or  typhoid  infection  should  be 
made. 

The  position  usually  assumed  in  the  severer  forms  is  upon  the  back,  with  the 
right  thigii,  or  probably  both  thighs,  flexed  upon  the  abdomen. 

In  gangrene  or  perforation,  or  with  rapidly  developing  peritonitis,  local  or 
general,  in  addition  to  tympanitis  and  general  rigidity  of  the  abdominal  muscles 
there  is  noticeable  an  expression  of  anxiety  or  fright.     Abdominal  breathing  is 

1  "Med.  Rec,"  May  11,  1907. 

=  "Mobile  Med.  and  Surg.  Jr.,"  January,  1907. 

5  Blow  -n-ith  a  baseball  in  the  author's  practice. 


442  APPENDICITIS,   PERITONITIS 

diminished  or  absent,  while  the  respiratory  movements  of  the  thorax  are  exag 


The  pulse  is  also  usually  increased  in  force  and  frequency  in  the  earlier  stages 
of  acute  appendicitis.  Should  perforation  or  gangrene  occur,  with  the  almost 
invariably  accompanying  shock,  the  pulse  becomes  at  once  weaker  and  more  rapid. 
The  average  leucocyte  count,  as  reported  by  Dr.  Ghriskey  in  one  hundred  cases  in 
the  practice  of  Dr.  John  B.  Deaver,  was,  in  acute  cases,  11,246;  with  pus  accumu- 
lation (abscess),  18,500;  in  chronic  cases,  8690.  In  the  highest  leucocytosis  the 
streptococcus  was  found;  next,  staphylococcus,  and  lowest,  the  colon  bacillus. 

There  is  in  general  an  elevation  of  temperature  in  proportion  to  the  rapid 
sjjread  of  the  infection.  However,  in  a  certain  proportion  of  instances  this  does 
not  hold  good.  In  the  first  hour  or  so  of  gangrene,  or  immediately  after  perfora- 
tion, the  temperature  may  fall  below  the  normal,  and  then  rapidly  rise  as  high 
as  103°  or  101:°  within  from  six  to  twelve  hours  of  the  first  S3-mptom. 

Nausea  and  vomiting  are  prominent  symptoms  of  these  more  dangerous  types, 
and  if  accompanied  by  intense  pain  should  excite  the  gravest  apprehension  and 
indicate  immediate  operation. 

The  moriid  changes  which  occur  in  the  region  of  the  appendix  vary  in  propor- 
tion to  the  severity  and  rapidity  of  the  septic  process.  In  the  milder  forms  a 
plastic  exudate  is  thrown  out  over  the  inflamed  area,  and  adhesions  are  formed  with 
contiguous  peritoneal  surfaces — intestinal,  omental,  mesenteric,  or  mural.  In  the 
center  of  this  exudate  most  frequently  pus  collects,  forming  an  abscess  of  variable 
size.  By  this  encapsulation  general  peritoneal  infection  may  be  prevented.  Should 
operation  be  deferred,  adhesions  may  continue  to  form  between  the  abscess  wall  and 
the  peritonseum  lining  the  abdomen,  either  in  front  or  laterally  in  the  direction  of 
the  right  iliac  spine  or  lumbar  region,  until  ultimately  the  abscess  may  be  opened 
without  entering  the  free  peritoneal  cavity;  or,  as  not  infrequently  occurs,  the 
adhesions  give  way  with  rapid  general,  and  too  often  fatal,  infection.  In  rarer 
forms,  especially  in  those  cases  in  which  the  cfecum  is  located  at  the  edge  of  the 
pelvis,  and  in  which  the  appendix  has  a  diiection  downward,  the  abscess  may 
encroach  upon  and  become  adherent  to  the  rectum,  bladder,  or  other  pelvic  organs. 
Examination  per  rectum  or  vagina  will  reveal  the  presence  of  the  tumor,  and  it  is 
often  advisable  to  ojDcn  such  abscesses  through  the  rectum  or  vagina  by  an  operation 
to  be  described.  In  very  exceptional  cases  suppuration  does  not  occur,  and  instead 
of  undergoing  fatty  metamorphosis  and  absorption  the  plastic  exudate  increases 
and  persists  for  months,  with  all  the  symptoms  and  history  of  a  rapidly  developing 
malignant  neoplasm,^  at  times  enveloping  the  CEecum,  appendix,  and  terminal  por- 
tion of  the  ileum. 

In  other  instances,  usually  with  perforation  or  gangrene,  the  infection  of  the 
peritonaeum  is  so  rapid  that  adhesions  cannot  form  in  time  to  prevent  a  general 
(diffuse)    peritonitis. 

Treatment. — Appendicitis  is  strictly  a  surgical  lesion,  and  in  the  hands  of  an 
experienced  surgeon,  without  regard  to  the  character  of  the  attack,  if  recognized 
within  the  first  twelve  hours  of  the  onslaught,  appendectomy  should  be  performed. 
By  pursuing  this  seemingly  radical  course,  the  death-rate  would  be  reduced  to  the 
minimum  (probably  not  to  exceed  two  per  cent),  while  the  serious  after-conse- 
quences in  recoveries  where  operation  has  been  delayed,  or  where  there  has  been  no 
surgical  intervention  would  be  avoided.  Even  where  the  diagnosis  may,  in  a  meas- 
ure, be  doubtful,  with  an  operator  of  experience  and  with  competent  assistants  at 
hand,  it  is  better  to  make  the  exploration  necessary  to  determine  the  exact  condi- 
tions and  permit  the  indications  to  be  met  than  to  incur  the  always  serious  danger 
of  dela3^ 

With  the  first  symptom  of  an  attack,  the  patient  should  rest  quietly  upon  the 
back,  with  a  slight  inclination  to  the  right  side.  The  bowels  should  be  freely  moved, 
castor  oil   (in  syrup  of  sarsaparilla)   lieing  the  remedy  of  choice.     If  this  is  not 

'  The  author  operated  upon  two  cases  of  this  character  breaking  up  adhesions  and  removing 
thick  organized  masses  of  solid  non-septic  exudate  in  the  center  of  which  the  remnant  of  the 
appendix  was  buried.  Both  recovered.  In  a  third  case  reported  to  him  excision  and  end-to- 
end  anastomosis  was  done. 


APPENDICITIS,    PERITOXITIS  443 

taken,  calomel  (in  triturate  form),  grs.  iij-v,  followed  in  six  hours  by  sulphate  of 
magnesia,  may  be  substituted.  Morphia  should  never  be  given  unless  the  pain  is 
unbearable,  and  only  then  to  give  relief  ■while  preparation  is  being  made  for  the 
operation. 

Technic  of  Appendectomy. — In  a  clean  case,  as  in  the  interval  between  attacks, 
or  in  acute  appendicitis  taken  sufficiently  early  to  forestall  serious  peritoneal  infec- 
tion, the  following  procedure  is  advised : 

The  skin  incision  is  at  least  four  inches  long,  parallel  with  the  fibers  of  the 
right  rectus  muscle,  about  one  inch  toward  the  Tinea  alba  from  the  right  edge 
of  this  muscle.  The  center  of  this  incision  should  be  one  half  inch  below  an 
imaginary  line  drawn  from  the  umbilicus  to  the  right  anterior  superior  spine  of 
the  ilium.  The  anterior  sheath  of  the  rectus  is  opened  on  this  plane,  a  pair  of 
dull-pointed  half-curved  scissors  carried  between  its  fibers  until  the}'  come  in  con- 
tact with  the  posterior  sheath,  when  they  are  turned  crossways  and  the  blades 
sufficiently  opened  to  separate  the  muscular  fibers.  In  this  opening  a  finger  is 
inserted,  and  with  it  the  separation  is  completed  in  the  length  of  the  incision. 
The  nerve  filaments  crossing  the  line  of  separation  shotild  be  held  apart  by  gentle 
traction,  and  never  divided  unless  it  is  absolutely  necessary.  Light  retraction  with 
dull-pointed  instruments  will  expose  the  posterior  sheath,  and  bring  into  view 
branches  of  the  inferior  epigastric  artery  and  vein.  When  possible,  these  should 
be  avoided,  but  when  they  cross  the  line  of  the  posterior  incision,  they  should  be 
secured  with  two  forceps,  divided  between,  and  tied  with  small  plain  catgut.  All 
bleeding  should  be  arrested  before  the  peritoneum  is  incised.  The  posterior  sheath 
and  the  peritonaeum  are  now  opened  in  the  general  direction  of  the  anterior  incision, 
but  not  for  more  than  one  inch.  The  posterior  sheath  may  be  sufficiently  devel- 
oped to  be  opened  separately,  or  it  and  the  peritonaeum  may  be  divided  together. 
A  Hagedorn  needle,  with  long  curve,  armed  with  a  Xo.  3  silk  or  linen  thread,  is 
entered  on  the  peritoneal  surface  one  half  inch  from  the  edge  of  the  incision, 
and  forced  directlj'  through  the  abdominal  wall  and  out  through  the  skin  on  each 
side  of  the  wound.  The  ends  are  tied  to  form  a  long  loop  retractor.  To  prevent 
any  possible  injury  to  the  omentum  or  intestine,  these  are  displaced  and  shielded 
by  the  bowl  of  a  small  spoon  introduced,  convex  surface  downward.  The  omentum, 
which  is  usually  encountered,  should  be  carefully  displaced  toward  the  median  line, 
and  anj-  overlying  loops  of  small  intestine  similarly  displaced.  In  certain  instances 
this  may  be  facilitated  by  half  turning  the  patient  on  the  left  side.  If  through 
this  small  peritoneal  opening  the  operation  cannot  be  thoroughly  accomplished 
without  unnecessary  manipulation,  it  should  be  enlarged  upward  or  do^vnward.  as 
required.  A  free  incision  is  much  less  harmful  than  the  rough  handling  which 
is  often  necessary  in  separating  adhesions  and  bringing  the  appendix  through  a 
small  aperture.  Should,  however,  the  appendix  present  favorably,  a  small  opening 
is  preferable.  When  (as  not  infrequently  occurs)  it  is  not  readily  located  by  the 
touch,  it  may  be  found  by  following  downward  the  longitudinal  band,  easily  recog- 
nized on  the  anterior  wall  of  the  colon  and  CEecum.^  This  band  terminates  in  the 
appei]dix.  In  children  three  or  four  years  old  the  appendix  may  be  near  the  costal 
arch  (Erdmann).  The  end  of  the  cscum,  with  the  appendix  and  meso-appendix 
attached,  should  be  brought  through  the  peritoneal  opening,  but  no  more  of  the 
cseeum  exposed  than  is  necessary  to  complete  the  operation  of  tying  off  the  meso- 
appendix  with  two  or  three  separate  loops  of  plain  catgut  ligature,  and  of  tying 
with  a  Xo.  2  silk  or  linen  thread  the  organ  to  be  removed.  The  meso-appendix 
is  divided  between  the  ligatures  and  the  appendix,  the  end  of  which  is  held  directly 
upward  until  it  may  be  clamped  by  an  artery  forceps  one  half  inch  from  its  junc- 
tion with  the  caecum.  A  No.  2  silk  or  linen  ligature  is  thrown  around  the  appendix 
one  quarter  of  an  inch  from  the  cseeum,  and  so  tightly  tied  that  there  can  be  no 
possible  chance  for  it  to  slip.  The  operator  should  Ije  sure  that  the  first  knot  holds 
firmly  while  the  second  is  being  secured.  As  soon  as  this  is  done  and  before  the 
ends  are  cut  awaj',  a  gauze  swab  split  half-way  with  the  scissors  is  carried  on.  either 
side  of  the  stump,  and  with  this  the  operator  firmly  holds  the  caecum.    The  appen- 

'  A  few  instances  are  on  record  where  operators  of  large  experience  after  prolonged  search 
have  failed  to  find  the  misplaced  appendix. 


444  APPENDICITIS,   PERITONITIS 

dix  is  divided  with  the  curved  scissors  one  quarter  of  an.  inch  beyond  the  ligature. 
The  presence  of  the  gauze  prevents  the  possibility  of  infection.  The  funnel-shaped 
end  of  the  stump  is  now  thoroughly  disinfected  with 'a  drop  or  two  of  pure  carbolic- 
acid  carried  upon  a  wisp  of  cotton  on  a  small  probe;  the  point  should  be  carried 
to  the  apex  of  the  funnel  and  rotated  until  all  the  surfaces  are  bleached  by  cauter- 
ization. One  or  two  drojDS  of  alcoliol  are  next  applied  in  the  same  way  to  neutralize 
any  excess  of  the  acid.  The  stump  should  be  thoroughly  dried,  the  silk  ligature 
divided  one  quarter  of  an  inch  from  the  knot,  the  swab  removed,  and  the  CEecum. 
permitted  to  drop  back  to  its  normal  position.  Within  a  few  hours  the  small  aseptic 
raw  surface  on  the  end  of  the  stump  beyond  the  ligatvire  is  covered  by  a  plastic: 
exudate  and  the  knot  is  buried.  When  the  removal  of  septic  exudate  or  fluid  is- 
necessary,  the  peritoneal  incision  should  be  larger.  If  the  operation  be  clean,  the 
omentum  should  be  brought  again  to  its  normal  position  in  front  of  the  cascum, 
and  the  peritoneal  incision,  with  that  of  the  posterior  sheath,  closed  by  a  running- 
suture  of  No.  2  chromicized  catgut.  This  part  of  the  technic  is  greatly  facilitated, 
by  traction  on  the  thread  loops  so  as  to  lift  the  abdominal  wall  and  peritongeum 
away  from  the  protruding  mesentery  or  intestine.  When  the  incision  is  long,  an 
additional  loop  retractor  should  be  inserted  near  each  angle.  When  the  peritongeum 
is  closed,  the  retractors  are  removed  and  the  separated  fibers  of  the  rectus  muscle 
are  permitted  to  resume  their  normal  position,  where  they  remain  without  suture. 
The  anterior  sheath  should  be  closed  with  a  running  suture  of  kangaroo  tendon. 
If  there  be  a  superabundance  of  fat,  a  subcutaneous  running  suture  of  No.  2  plain- 
catgut  is  advisable  for  its  approximation.  An  endocuticular  suture  of  silkworm  gut 
should  close  the  anterior  incision.  A  light  dressing  of  sterile  gauze,  held  in  place 
by  firm  pressure  with  adhesive  strips  or  an  abdominal  bandage,  will  suffice.  The 
silkworm-gut  suture  should  be  removed  about  the  eighth  day. 

'  Preference  is  given  the  Deaver  incision  because  it  gives  free  access  to  the  cascum 
and  appendix,  and  when,  as  is  not  infrequent,  it  becomes  necessary  to  have  more 
room  for  safe  and  thorough  work,  it  can  be  extended  indefinitely  upward  or  down- 
ward, giving  complete  command  of  the  peritoneal  cavity  with  the  minimum  of 
risk  of  being  followed  by  ventral  hernia.  The  only  objection  to  it  is  the  occasional 
division  of  one  (rarely  more)  of  the  dorso-lnmbar  nerve  filaments  which  cross  it 
to  supply  the  rectus.  The  closure  of  the  peritonteum,  the  strong  muscular  splint 
which  guards  this  posterior  incision,  together  with  the  firm  union  which  can  be 
obtained  in  the  sheath,  makes  a  ventral  hernia  a  rare  exception.  I  prefer  it  to  the 
Kammerer  method,  which,  making  the  same  anterior  and  posterior  incision,  dis- 
places temporarily  the  right  edge  of  the  rectus  toward  the  median  line.  Jly  chief 
objection  to  the  latter  is  that  when  drainage  is  found  to  be  necessary,  the  muscle 
resuming  its  normal  position,  forms  a  trapdoor  over  the  posterior  opening.  Both 
are  preferable  to  McBurney's  incision,  for  the  reason  that  it  cannot  be  sufficiently 
enlarged  to  meet  an  emergency  without  great  dang'er  of  ventral  hernia. 

Numerous  accidents  from  hfemorrhage  or  giving  way  of  the  suture,  some  of 
them  fatal,  have  followed  other  methods  than  the  simple  ligature.  Any  suture 
method  is  unnecessary,  and  violates  an  essential  principle  of  surgery,  viz.,  the 
minimum  of  traumatism. 

When  an  abscess  or  septic  exudate  is  encountered,  the  peritoneal  incision  should 
be  enlarged  so  as  to  give  a  full  view  of  and  free  access  to  the  septic  area,  and,  if 
necessary,  the  abdominal  incision  should  also  be  further  extended  upward  or  down- 
ward. It  is  imperative  to  prevent,  if  possible,  contact  of  all  peritoneal  surfaces  not 
already  involved  with  septic  matter.  To  accomplish  this  it  is  often  necessary  to 
wall  ofiE  the  diseased  area  with  sterile  mats  or  loose  absorbent  gauze.  A  careful 
count  should  be  kept  of  separate  pieces  so  that  by  oversight  none  may  be  left  in 
the  abdomen,  and  it  is  a  wise  precaution  to  have  a  string  or  tape  attached  to  each 
with  a  forceps  fastened  to  the  free  end.  By  means  of  the  author's  loop  retractors  the 
abdominal  wall  may  be  lifted,  when  there  will  be  space  so  free  that  these  mats  may 
be  inserted  with  expedition  and  the  minimum  of  traumatism.  With  this  carefully 
accomplished,  adhesions  may  now  be  broken  up  by  the  finger  of  the  operator,  and 
the  appendix  with  the  exudate  and  stump  of  the  CEeeum  brought  up  to  the  edges 
of  the  incision.    If  in  the  process  of  breaking  up  adhesions  pus  is  encountered,  it 


APPENDICITIS,   PERITONITIS  445 

should  at  once  be  mopped  out  with  sterile  gauze  swabs.  The  appendix  should  now 
be  tied  oS  and  the  stump  treated  as  in  the  preceding  operation,  and  all  septic 
matter,  either  exudate  or  liquid,  thoroughly  removed  with  sponges  or  swabs.  It 
zaay  be  necessary  in  rare  cases  to  clip  with  the  curved  scissors  masses  or  fragments 
of  septic  exudate,  which  adhere  to  the  \^'alls  of  the  cajcum,  ileum,  or  mesentery, 
and  to  tie  off  and  remove  any  masses  of  omentum  fo\ded  with  this  exudate. 

The  question  will  now  confront  the  surgeon  whether  or  not  he  shall  close  the 
abdominal  wound  without  drainage.  If  the  patient  is  young  and  vigorous — in 
■other  words,  if  the  resistance  is  near  the  normal — and  if  the  area  of  infection  is 
small  and  a  thorough  cleansing  has  been  effected,  the  gauze  pads  may  be  removed 
and  the  wound  closed  as  just  described.^ 

If,  on  the  contrary,  there  is  serious  doubt  as  to  the  propriety  of  closure  without 
■drainage,  he  should  lean  to  the  side  of  conservatism  and  drain,  if  only  temporarily. 

The  objections  to  drainage  are  that  it  favors  the  formation  of  adhesions,  and 
Tveakens  the  abdominal  incision  at  the  point  through  which  the  drain  makes  its 
■exit.  However,  in  severe  infections  these  risks  must  l)e  incurred  rather  than  the 
^eater  one  of  diffuse  peritonitis.  As  a  rule,  the  ordinary  cigarette  drain  is  all 
that  is  necessary.  This  is  made  by  enclosing  one  or  several  loose  wisps  or  pencils 
■of  absorbent  gauze  in  a  layer  of  rubber-tissue  protective,  the  gauze  projecting 
slightly  from  both  ends.  One  end  is  carried  to  the  center  of  the  infected  area, 
usually  at  the  stump,  and  passes  directly  upward  to  the  most  convenient  point  of 
the  abdominal  incision.  In  order  to  prevent  displacement  the  inner  end  of  the 
drain  should  be  fastened  at  the  center  of  infection  by  a  single  small  plain  catgut 
suture.  The  peritoneal  and  the  abdominal  wounds  are  then  closed  from  either 
end  lip  to  the  drain.  As  it  is  intended  to  remove  this  within  forty-eight  or 
seventy-two  hours,  it  is  a  wise  precaution  to  introduce  one  or  two  silkworm-gut 
sutures  through  the  skin  and  sheath  of  the  rectus,  then  through  the  peritonseum 
•across  to  the  opposite  side,  and  out  through  the  same  tissues.  These  sutures  are 
left  long  so  that  when  the  drain  is  removed  they  may  be  tied,  and  thus  secure 
firm  closure  of'  an  otherwise  weak  point  in  the  abdominal  incision. 

If  at  any  time  a  high  temperature  or  tjTnpanitis,  accompanied  by  other  symp- 
toms of  renewed  infection  and  spreading  peritonitis,  should  be  present,  the  surgeon 
should  without  delay  open  the  wound  and  meet  the  indications. 

If  the  conditions  are  such  as  to  require  more  than  temporary  drainage,  a  rubber 
drain  may  be  required.  A  piece  of  soft-rubber  tubing,  varying  in  diameter  from 
one  quarter  to  one  half  inch,  and  at  times  larger,  and  long  enough  to  reach  from 
the  stump  of  the  appendix  and  to  come  out  through  the  abdominal  *all,  should 
he  split  from  end  to  end  spirally  (the  spiral  making  about  one  turn),  and  loosely 
filled  with  wisps  of  absorbent  gauze.-  The  size  will  depend  upon  the  conditions 
which  are  present,  but  one  a  half  inch  in  diameter  will  usually  suffice.  At  times 
two  of  these  tubes  may  be  necessary,  placed  side  by  side. 

In  rare  instances  it  may  be  deemed  more  advisable  to  wall  off  the  uninvolyed 
peritoneal  surfaces  with  sterile  gauze,  either  loose  or  in  mats,  leaving  these  in 
place  about  forty-eight  hours  until  adhesions  have  formed.  When  the  original 
pack  is  removed,  which  should  be  done  imder  nitrous-oxide  gas,  a  smaller  secondary 
pack  may  be  required,  and  this  can  be  removed  in  twenty-four  or  forty-eight  hours, 
generally  without  narcosis.  In  all  these  cases  of  packing  it  is  my  invariable  practice 
to  insert  through-and-through  silkworm-gut  sutures  one  quarter  of  an  inch  apart 
for  the  entire  length  of  the  incision,  leaving  the  ends  long  so  that  plenty  of  room 
may  be  had  for  removing  and  replacing  the  pack.  Y\''ith  the  first  change  one  or 
two  of  the  sutures  at  each  end  may  be  tied,  followed  from  time  to  time  by  the  others 
as  the  pack  is  gradually  discontinued. 

While  with  the  Deaver  incision  (splitting  the  rectiis)  the  danger  of  ventral 
hernia  is  reduced  to  the  minimum,  it  may  follow  in  these  drainage  cases,  even  where 
the  precautions  just  advised  have  been  thoroughly  carried  out. 

'  Should  the  patient  be  in  a  hospital  where  at  any  hour  of  the  day  or  nisrht,  upon  the  first  in- 
dication of  recurring  infection,  a  second  operation  maybe  done  with  the  establishment  of  drainage, 
the  surgeon  will  often  be  justified  in  adopting  this  plan. 

'  Dr.  Van  Buren  Ivnott. 


446  APPENDICITIS,   PERITONITIS 

The  operative  measures  above  given  will  apply  equally  in  all  cases  of  perforated 
and  gangrenous  appendicitis,  but  not  in  general  diffuse  peritonitis. 

In  delayed  cases,  where  an  abscess  of  large  size  has  been  formed,  temporary 
drainage  through  the  smallest  possible  puncture  or  incision  is  safer  than  an  effort 
to  remove  by  a  radical  operation  an  extensive  septic  exudate.  In  these  cases  adlie- 
sions  may  exist  between  the  abscess  wall  and  the  abdominal  peritonaeum,  so  that 
the  abscess  may  be  reached  without  passing  through  the  peritoneal  cavity. 

When  the  focus  of  infection  is  below  the  rim  of  the  pelvis,  the  wall  of  the 
abscess  not  infrequently  is  adherent  to  the  recaim  or  vagina,  through  either  of 
which  it  may  be  evacuated  by  puncture.  When  the  tumor  may  be  reached  directly 
over  the  appendix,  the  JMcBurney  incision  is  advised.  A  small  cut  not  more  than 
two  inches  long,  parallel  with  and  about  one  inch  to  the  right  of  the  linea  semi- 
lunaris, exposes  the  fibers  of  the  ajDoneurosis  of  the  external  oblique  which  are  split 
and  held  apart  by  dull  retractors.  The  fibers  of  the  internal  oljlique  and  trans- 
versalis  are  also  sejDarated  and  held  apart  by  retraction.  If  the  peritonaeum  is 
agglutinated  to  the  underlying  mass,  an  aspirator  needle  should  be  carefully  in- 
serted in  the  direction  of  the  center  of  the  tumor  in  order  to  demonstrate  the  jDres- 
ence  of  pus  and  the  thickness  of  the  abscess  wall.  When  pus  appears  the  needle 
should  be  withdrawn,  and  a  dull-pointed  dressing  forceps  carried  along  the 
track  of  the  needle  until  it  slips  into  the  cavity  of  the  abscess,  when  by  separation 
of  the  blades  a  free  exit  is  established.  One  or  two  drainage-tubes  should  now  be 
inserted  and  the  pus  allowed  to  discharge  itself.  Should  irrigation  be  deemed 
advisable  it  should  be  done  without  undue  pressure  for  fear  of  breaking  through 
adhesions  and  spreading  infection.  If  adhesions  between  the  mass  and  the  peri- 
toneum have  not  formed,  it  is  advisable  to  incise  the  latter  for  about  an  inch  and 
insert  a  small  jDack  of  gauze,  leaving  this  in  situ  for  thirty-six  to  forty-eight  hours 
to  secure  adhesions  before  opening  the  abscess. 

If  the  pus  has  drifted  toward  the  lumbar  region  the  incision  should  be  made 
there,  and  when  digital  examination  recognizes  the  tumor  in  the  pelvis,  puncture 
and  drainage  may  be  made,  preferably  through  the  rectum  or  through  the  vagina. 

The  danger  incurred  in  the  effort  to  remove  these  vei-y  extensive  areas  of  infec- 
tion by  an  open  radical  operation  is  great  for  the  reason  that  the  subjects,  as  a 
rule,  are  exhausted  by  prolonged  sepsis.  It  is  safer  to  practice  drainage  until 
the  discharge  has  entirely  ceased  or  until  the  size  of  the  infected  area  is  reduced 
to  the  minimum,  and  the  normal  resistance  of  the  patient  is  restored,  and  later 
in  a  period  of  quiescence  through  a  Deaver  incision  to  remove  the  appendix. 

In  cases  of  appendicitis  where  operation  is  declined  or  where,  for  any  reason, 
the  physician  or  surgeon  in  charge  deems  operation  inadvisable,  the  method  of 
treatment  advised  by  Dr.  A.  J.  Ochsner  should  be  practiced. 

This  distinguished  surgeon  bases  what  may  be  called  the  treatment  of  absolute 
rest  upon  the  claim,  first,  that  "  the  distribution  or  extension  of  the  infection  is 
accomplished  by  peristaltic  action  of  the  small  intestines,  after  the  infection  has 
extended  beyond  the  appendix  and  before  it  has  become  circumscribed." 

"  Peristalsis  can  be  prevented  by  prohibiting  the  use  of  every  form  of  nourish- 
ment and  cathartic  by  mouth,  and  by  employing  gastric  lavage  in  order  to  remove 
any  food  substances  or  mucus  from  the  stomach." 

"  The  patient  can  be  safely  nourished  during  the  necessary  period  of  time  by 
means  of  nutrient  enemata.  Large  enemata  should  never  be  given,  for  they  may 
cause  the  rupture  of  an  abscess  into  the  peritoneal  cavity." 

Ochsner  notes  that  "  when  neither  food  nor  cathartic  are  given  from  the  begin- 
ning of  the  attack  of  acute  appendicitis  and  gastric  lavage  is  employed,  the  mortal- 
ity is  reduced  to  an  extremely  low  percentage." 

"  In  cases  which  have  received  some  form  of  food  and  cathartics  during  the 
early  portion  of  the  attack,  and  are  consequently  suffering  from  a  beginning  diffuse 
peritonitis  when  they  come  under  treatment,  the  mortality  will  still  be  less  than 
four  per  cent  if  peristalsis  is  inhibited  by  the  use  of  gastric  lavage  aod  the  aljsolute 
prohibition  of  all  forms  of  nourishment  and  cathartics  by  rrrouth.  ^n  this  manner 
very  dangerous  cases  of  acute  appendicitis  may  be  changed  into  relatively  harmless 
chronic  cases." 


APPENDICITIS,   PERITONITIS  447 

Oehsner  insists  that  even  ''during  the  beginniag  of  this  treatment  no  water 
should  be  given  by  mouth,  the  thirst  being  quenched  by  rinsing  the  mouth  with 
cold  water  and  the  use  of  small  enemata.  Later  small  sips  of  very  hot  water,  fre- 
quently repeated,  may  be  given,  and  still  later  cold  water  in  the  same  way.  There 
is  danger  in  giving  water  too  freely,  and  there  is  great  danger  in  the  u^e  of  large 
enemata."' 

"  It  should  be  constantly  borne  in  mind  that  even  the  slightest  amount  of  liquid 
food  of  any  kind  given  by  mouth  may  give  rise  to  dangerous  peristalsis.  The  most 
convenient  form  of  rectal  feeding  consists  in  the  use  of  one  ounce  of  any  of  the 
various  concentrated  liquid  predigested  foods  in  the  market  dissolved  in  three 
ounces  of  warm  normal  salt  solution  introduced  slowly  through  a  soft  catheter 
inserted  into  the  rectum  a  distance  of  two  to  three  inches."  He  also  states  that 
"  this  form  of  treatment  -cannot  supplant  the  operative  treatment  of  acute  appen- 
dicitis, but  it  can  and  should  be  used  to  reduce  the  mortality  by  changing  the  class 
of  cases  in  which  the  mortality  is  greatest  into  another  class  in  which  the  mortality 
is  very  small  after  operation." 

In  practicing  lavage,  which  he  considers  so  essential  in  the  successful  manage- 
ment of  these  eases,  he  advises  spraying  the  pharynx  with  two-per-cent  cocaine, 
waiting  from  five  to  seven  minutes  until  a  local  anEesthetic  effect  is  experienced, 
then  introducing  a  stomach-tube  and  irrigating  with  warm  normal  salt  solution. 
iSTo  food  of  any  kind  whatsoever  or  cathartic  should  be  given  by  mouth  until  the 
patient  has  been  normal  for  four  days,  no  matter  whether  or  not  an  immediate 
operation  be  performed.     The  enemata  are  given  every  three  to  four  hours. 

Peritonitis. — Infection  of  the  peritonseum  may  be  traumatic  or  idiopathic,  local 
or  general. 

Penetrating  wounds,  or  injuries  which  involve  the  muscular  walls  and  become 
infected,  are  apt  to  induce  peritonitis.  Hard  or  pointed  ingested  substances  occa- 
sionally penetrate  the  walls  of  the  alimentary  canal,  permitting  the  escape  of  patho- 
genic organisms  into  this  cavity.  As  already  stated  in  the  chapter  which  treats 
of  appendicitis,  complete  rupture  or  destruction  by  disease  of  all  of  the  coats  which 
compose  the  wall  of  any  portion  of  the  alimentary  tract,  or  in  fact  of  any  one 
layer,  is  not  necessary  to  peritoneal  infection.  In  gangrene  due  to  sudden  arrest 
of  the  blood  supply,  where  there  is  no  actual  breach  of  continuity,  the  leucocytes 
are  no  longer  present  in  force  sufficient  to  resist  invasion.  In  other  words,  the 
tissues  have  lost  their  normal  resistance  and  infection  ensues.  An  ulcer  which 
destroys  no  more  than  the  mucous  lining  may  so  impair  the  resistance  of  the  inter- 
vening muscular  layer  that  the  peritonteum  becomes  involved. 

Idiopathic  peritonitis  is  almost  always  due  to  the  spread  of  an  infective  process 
from  one  or  more  of  the  organs  with  which  this  membrane  is  in  contact.  While  it 
is  possible  that  the  organisms  of  sepsis  may  be  carried  by  the  blood  or  lymph  chan- 
nels, and  may  fuid  a  lodgment  on  any  portion  of  the  peritoneal  surface  where  the 
local  conditions  are  favorable  to  their  proliferation,  such  a  method  of  infection  is 
extremely  rare.  It' occurs  as  a  complication  of  diaphragmatic  pleurisy,  abscess  of 
the  liver,  sejjtic  infarctions  of  the  spleen,  gastric  and  duodenal  ulcer,  empyema  or 
iilcer  of  the  gall  bladder,  inflammation  of  the  gall  ducts,  pancreatitis,  enterocolitis, 
appendicitis,  peri-nephritic  infection,  and  very  frequently  from  specific  or  pyogenic 
infections  of  the  genito-urinary  organs.  The  necrotic  process  resulting  from  intus- 
susception, volvulus,  strangulated  hernia,  weakens  the  resistance  of  even  the  un- 
broken intestinal  wall  and  permits  the  outward  passage  of  septic  micro-organisms. 

The  most  common  pathogenic  organisms  in  acute  peritonitis  are  the  strepto- 
coccus, staphylococcus,  bacillus  coli  communis,  and  gonococcus.  The  bacillus 
typhosus  and  pneumococcus  are  occasionally  present,  but  even  in  peritonitis  com- 
plicated with  typhoid  ulcer,  with  or  without  perforation,  the  severity  of  the  symp-, 
toms  is  almost  always  due  to  the  streptococcus  and  staphylococcus. 

Symptoms  and  Diagnosis. — The  symptoms  of  peritonitis  vary  in  large  measure 
with  the  virulence  and  rapid  spread  of  the  infection.  In  many  instances  the  attack 
is  so  insidious  and  mild  that  the  character  of  the  infection  is  with  difficulty  recog- 
nized. Pain  is  usually  the  first  symi^tom,  and  in  the  more  rapidly  developing  cases 
is  severe  and  persistent.    It  is  usually  referred  to  the  focus  of  infection,  although 


448  '    PERITONITIS 

in  a  certain  proportion  of  cases  the  painful  sensations  are  referred  to  the  neighbor- 
hood of  the  umbilicus.  As  a  rule,  deep  or  point-pressure  with  a  single  finger  will 
elicit  a  more  acute  sense  of  pain  at  the  seat  of  the  lesion  than  elsewhere.  Muscular 
resistance  or  rigidity  is  one  of  the  most  unfailing  indications  of  the  location  of  a 
beginning  peritonitis.  Nausea,  with  or  without  vomiting,  is  a  frequent  early 
symjDtom,  and  if  prominent  as  a  symptom  suggests  acuteness  and  rapidity  of  the 
invasion.  Shock  is  almost  always  present  in  varying  degree  with  jjerforation,  intus- 
susception, volvulus,  or  gangrene.  The  expression  of  the  face  is  one  of  anxiety  in 
these  more  severe  attacks  (tacies  abdominalis).  Abdominal  breathing  is  less  than 
normal,  while  the  respiratory  movements  of  the  thorax  are  increased.  In  non- 
perforative  cases  the  pulse  is  usually  increased  in  force  and  frequency.  In  the 
early  stages  of  acute  localized  peritonitis  the  temperature  does  not  vary  far  from 
the  normal.  In  many  instances  it  is  subnormal,  and  this  is  rather  an  alarming 
symptom.  If  with  a  suspected  peritonitis  there  is  a  subnormal  temperature,  rising 
above  the  normal  one  or  two  degrees  within  as  many  hours,  the  indications  for 
exploration  are  positive,  although  in  a  certain  proportion  of  cases  this  symptom 
is  deceptive.  Knowledge  of  a  preexisting  lesion  should  be  considered  in  locating 
the  focus  of  invasion.  Ulcers  of  the  stomach  and  duodenum  not  infrequently 
break  down  and  induce  overwhelming  peritonitis  from  perforation.  The  same  is 
true  of  ulcer  of  the  gall  bladder,  and  of  any  continuous  infective  process  of  the 
lining  membrane  of  the  alimentary  canal  (typhoid  ulcer).  The  history  of  a 
specific  infection  of  the  genito-urinary  apparatus,  with  deep-seated  pains  in  the 
lower  abdomen  and  even  a  slight  rise  of  temperature,  would  justify  the  suspicion 
of  commencing  peritonitis. 

Prognosis. — The  prognosis  in  peritonitis  depends  upon  the  location  of  the  in- 
fection, the  rapidity  of  invasion,  the  condition  of  resistance  of  the  patient  at  the 
time  of  the  attack,  and  in  large  measure  upon  the  promptness  of  surgical  relief. 
Peritonitis  resulting  from  perforation  is  always  a  grave  condition.  If  the  perfora- 
tion is  of  large  size,  with  free  extravasation,  the  danger  is  greatly  increased.  A 
peritonitis  due  to  perforation  or  infection  in  the  subdiaphragmatic  zone  is  extraor- 
dinarily dangerous,  for  the  reason  that  the  lymphatic  absorption  at  this  part  of 
the  abdomen,  especially  near  the  center  of  the  diaphragmatic  arch,  is  very  rapid, 
and  at  times  overwhelming.  Moreover,  the  peritonitis  is  apt  to  spread  rapidly  by 
gravitation  to  other  portions  of  the  general  cavity.  Infection  due  to  the  escape 
of  organisms  from  the  region  of  the  appendix  and  the  first  part  of  the  colon  is 
usually  more  virulent  than  that  caused  lay  escape  of  contents  from  the  small  intes- 
tine higher  up,  for  the  reason  that  the  first  part  of  the  colon  is  the  main  breeding- 
ground  of  the  most  virulent  septic  germs. 

Treatment.— The  first  indication  in  the  treatment  of  peritonitis  is  absolute  rest 
in  that  position  which  will  best  prevent  the  spread  of  infection  until  surgical  relief 
can  be  obtained,  or,  failing  in  this,  until  adhesions  with  encapsulation  of  the  in- 
fective process  may  be  established.  The  logical  treatment  of  a  peritoneal  infection 
is  immediate  incision,  with  removal  of  the  focus  of  invasion  and  a  careful  local 
toilet  of  the  peritonjeum,  removing  all  foreign  or  septic  matter,  and  when  possible 
immediately  closing  the  abdominal  incision.  The  question  of  drainage  in  any 
given  case  must  be  determined  by  the  conditions  which  are  found.  In  an  individual 
in  whom  the  resistance  is  near  the  normal,  with  a  localized  infection  recognized 
within  the  first  few  hours  of  invasion  and  subjected  to  operation  and  a  neat  toilet, 
as  a  rule  immediate  closure  without  drainage  may  be  done.  When,  however,  the 
resistance  is  low  and  there  is  any  suspicion  in  the  mind  of  the  operator  of  the 
ability  of  the  peritouEeum  and  its  leucocytes  to  combat  the  invasion,  it  is  better 
to  lean  to  the  side  of  conservatism  and  establish  a  temporary  and  usually  restricted 
drainage.  In  cleansing  a  limited  area  of  infected  peritonaeum  it  is  advisable  to  use 
no  irrigation,  but  to  remove  with  swabs  wet  in  sterile  salt  solution  or  mercuric 
chloride  1-3000  all  extravasated  or  septic  material,  always  taking  the  precaution 
when  the  mercuric  solution  is  employed  to  remove  any  possible  excess  by  a  final 
cleansing  with  the  swabs  wet  in  the  salt  solution.  When  drainage  is  employed  in 
incipient  local  peritonitis,  the  cigarette  drain  is  usually  sufficient.  This  is  composed 
of  a  wick  or  film  of  absorbent  gauze,  wrapped  loosely  about  with  one  or  two  layers 


PERITONITIS  449 

of  sterile  rubber-tissue  protective.  One  end  sliould  rest  at  the  seat  of  infection, 
and  if  necessary  it  may  be  anchored  at  that  point  by  a  single  ordinary  catgut  suture 
25assed  through  the  end  of  the  gauze,  which  should  project  slightly  beyond  the 
rubber  tissue,  stitching  it  to  the  tissues  at  the  point  of  infection.  The  other  end 
should  pass  out  at  the  most  convenient  point  upon  the  abdominal  incision.  As 
directed  in  celiotomy,  when  a  drain  is  left  projecting  through  an  abdominal  incision 
a  through-and-through  silkworm-gut  loop  should  be  inserted,  and  left  long  so  that 
when  the  drain  is  removed  at  the  end  of  twenty-four  or  forty-eight  hours  this  suture 
can  be  tied,  bringing  the  peritoneum  and  abdominal  wound  together,  and  thus 
preventing  hernia.  When  the  peritonitis  becomes  general  or  diffuse,  more  heroic 
measures  of  treatment  are  necessary.     These  will  be  given  on  another  page. 

N on-operative  Treatment.- — When  for  any  reason  operation  is  delayed,  the  pa- 
tient should  be  placed  in  bed  and  in  the  position  best  calculated  to  prevent  a  spread 
of  the  infection.  If  there  is  a  beginning  peritonitis  in  the  right  iliac  fossa  (appen- 
dicitis) the  patient  should  rest  upon  the  back,  with  the  shoulders  well  elevated 
(Fowler's  position),  with  a  sliglit  inclination  to  the  right  side.  In  any  lesion  of 
the  pelvis  inducing  peritonitis,  the  extreme  Fowler  position  should  be  maintained. 
If  subdiaphragmatic  peritonitis  is  suspected,  the  patient  should  rest  flat  upon  the 
back,  with  an  elevation  of  the  foot  of  the  bed  eight  or  ten  inches,  with  an  inclina- 
tion to  one  side  or  the  other  if  there  is  thought  to  be  a  lateral  focus  of  infection. 

When  a  lesion  of  any  jiortion  of  the  walls  of  the  alimentary  canal  is  thought 
to  exist  and  to  cause  the  peritonitis,  a  general  purgative  is  not  indicated,  unless 
severe  intestinal  toxasmia  is  present.  It  is  then  advisable  to  empty  the  bowels  by 
the  administration  of  castor  oil,  or  from  three  to  five  grains  of  calomel  triturates. 
If  the  upper  end  of  the  alimentary  canal  is  involved  and  the  necessity  for  emptying 
the  bowels  is  present,  irrigation  of  the  colon  should  be  done.  In  non-operative 
cases  where  pain  is  severe,  and  where  it  is  deemed  advisable  to  keep  the  alimentary 
canal  in  quiescence,  the  administration  of  morphia  may  in  rare  instances  be  per- 
missible. The  local  applications  of  cold  or  heat  by  means  of  a  light  rubber  ice-bag 
or  by  means  of  the  rubber  hot-water  bag,  gives  at  times  a  sense  of  relief.  The 
Ochsner  method  as  advised  in  non-operative  appendicitis  should  be  equally  bene- 
ficial in  peritonitis. 

General  Suppurative  Peritonitis. — In  the  treatment  of  widespread  infection  of 
the  peritoneal  cavity  the  immediate  indication  is  to  remove  the  focus  of  infection, 
together  with  all  septic  exudate  which  may  be  encountered.  If  the  location  of  the 
original  point  of  infection  is  satisfactorily  established,  the  incision  through  the 
abdominal  wall  should  of  necessity  be  made  so  as  to  permit  free  access  to  this 
location.  The  rules  governing  these  incisions  have  been  given  in  the  chapter  on 
celiotomy.  The  method  of  removing  the  gas  and  semiliquid  ingesta  from  the  hyper- 
distended  intestines  has  been  given. 

Such  is,  in  general,  the  patient's  low  resistance,  due  to  overwhelming  septicemia, 
that  time  is  more  than  ordinarily  an  important  factor  in  dealing  successfully  with 
this  condition.     The  incision  should  only  be  large  enough  to  give  free  command  of 


Fig.  474. — Blake's  abdominal  irrigator.     (Kny-Scheerer.) 

the  infected  area.  In  cleansing  the  general  peritoneal  cavity  the  abdominal  ^irrigator 
devised  by  Prof.  Joseph  A.  Blake  will  be  found  most  satisfactory.  It  permits  of 
a  direct  inflow  through  a  straight  central  tube,  while  the  return  current  is  siphoned 
through  the  lateral  perforations  in  the  enlarged  end,  and  escapes  by  way  of  the 
outer  tube.  "  The  combined  area  of  the  lateral  perforations  is  much  greater  than 
that  of  the  outflow,  thereby  preventing  undue  suction  upon  intestine  or  omentum." 
This  instrument  is  made  in  two  sizes:  that  for  adults  fourteen  inches  long,  the 
smaller  about  one  third  less  in  all  dimensions  (Fig.  474).    It  can  be  entirely  taken 


450  PERITONITIS 

apart  for  cleansing.  In  its  employment  it  is  connected  to  the  reservoir  with  a 
large  rubber  tube,  in  order  to  get  a  rapid  inflow.  A  short  piece  of  rubber  tubing, 
not  over  twelve  inches  long,  is  connected  with  the  outflow.  If  this  tube  be  too 
long,  there  is  danger  of  injury  to  the  intestines  from  violent  suction.  It  should 
be  held  in  the  hand  in  such  a  way  that  the  inflow  and  return  can  be  easily  con- 
trolled by  pressure  of  the  fingers. 

In  order  for  the  instrument  to  work,  it  is  necessary  to  establish  a  siphon  action 
through  the  outflow,  inasmuch  as  the  end  in  the  abdomen  is  usually  lower  than  the 
part  of  the  tube  outside.    If  this  is  not  done,  it  works  only  as  an  ordinary  irrigator. 

To  establish  the  siphon  the  margins  of  the  wound  should  be  compressed  about 
the  shank  of  the  tube,  when  the  inflow  will  cause  sufficient  intra-abdominal  pressure 
to  force  the  irrigating  fluid  back  through  the  outflow,  thus  making  the  siphon.  If 
the  instrument  has  to  be  withdrawn  in  order  to  insert  it  in  another  direction,  and 
there  is  danger  of  air  entering  and  breaking  the  siphon,  it  is  only  necessary  to 
compress  and  fold  the  rubber  outlet  tubing  against  the  metal  with  the  fingers,  thus 
closing  it  and  preventing  it  from  emptying.  It  is  well,  if  possible,  to  pass  the 
fingers  of  the  left  hand  into  the  abdomen  and  partially  surround  the  tube  with 
them,  thus  preventing  occlusion  of  the  lateral  apertures.  The  degree  of  cleanliness 
reached  is  at  once  evident  by  the  character  of  the  outflow,  and  when  this  becomes 
clear  the  irrigator  is  passed  to  another  fossa  of  the  abdomen.  In  this  way  each 
peritoneal  pocket  can  be  successively  cleansed,  and  at  the  same  time  an  accurate 
estimation  of  the  diffusion  of  the  exudate  or  foreign  material  be  obtained.  Foreign 
material  too  coarse  to  pass  through  the  apertures  will  on  account  of  the  suction 
stick  to  them,  and  in  this  way  large  pieces  of  foreign  substances  may  be  removed, 
together  with  patches  of  fibrin,  etc.  It  has  the  one  very  great  advantage  of  being 
used  with  a  very  small  incision.^ 

If  this  apparatus  is  not  at  hand,  a  fair  substitute  may  be  had  in  a  jjiece  of 
stiff  rubber  drainage-tube,  from  one  quarter  to  one  half  inch  in  diameter  and 
long  enough  to  reach  from  a  median-line  incision  to  any  part  of  the  abdominal 
cavity.  Irrigation  with  hot  salt  solution,  at  a  temperature  from  115°  to  120°  F., 
should  be  used,  always  beginning  in  the  upper  part  of  the  abdomen,  flooding  the 
region  behind  and  in  front  of  the  stomach,  the  liver,  spleen,  transverse  colon,  down 
along  the  region  posterior  to  the  ascending  and  descending  colon,  and  a  final  thor- 
ough irrigation  of  the  pelvis.  As  a  part  of  this  general  peritoneal  toilet  and  drain- 
age, the  extreme  Fowler  position  should  be  maintained  and  free  pelvic  drainage 
instituted.  When  an  irrigator  or  fountain  apparatus  is  not  at  hand,  the  hot  salt 
solution  may  be  poured  in  from  sterile  pitchers  held  at  a  sufficient  height  above 
the  gaping  abdominal  incision.  A  longer  incision  may  be  required  than  when  the 
irrigator  is  employed.  In  women  it  is  advisable  to  open  freely  through  Douglas's 
cul-de-sac,  and  insert  a  large  size  Van  Buren  Knott  rubber  drainage-tube,  which  is 
loosely  packed  with  iodoformized  or  sterile  absorbent  gauze.  In  males,  two  tubes 
should  be  inserted  in  the  middle  line,  immediately  above  the  symphysis  pubis.  The 
lower  and  larger  of  these  should  be  at  least  one  inch  in  diameter,  split  spirally  from 
end  to  end,  and  filled  with  a  strip  of  absorbent  gauze.  Above  and  in  contact  with 
this  a  second  tube  of  smaller  size  should  be  inserted.    This  tube  contains  no  gauze. 

The  question  of  a  local  cigarette  drain  at  the  focus  of  infection  must  be  deter- 
mined by  the  conditions  which  it  is  sought  to  correct.  The  irrigation  with  hot 
salt  solution  from  above  should  be  continued  until  the  fluid  which  escapes  through 
the  points  of  drainage  is  satisfactorily  clear  and  clean.  The  operative  wound  should 
be  closed  without  any  attempt  to  remove  the  excess  of  solution,  some  of  which  will 
escape  by  the  drainage,  the  remainder  being  absorbed  by  the  peritongeum.  Any 
collection  of  fluid  in  the  smaller  of  the  two  lower  tubes  should  be  carefully  with- 
drawn by  suction  with  a  syringe  and  rubber  tube  every  hour  or  so,  an  accumulation 
not  being  permitted. 

In  closing  the  incision,  a  rapid  through-and-through  silkworm-gut  closure  may 
be  necessary  rather  than  take  the  time  required  for  separate  layer  sutures.  The 
shortest  time  consistent  with  thoroughness  and  the  minimum  of  'ether  or  chloroform 
are  all  important. 

"  Prof.  Joseph  A.  Blake,  "Surg.,  Gyn.  and  Obstet.,"  May,  1906. 


PERITONITIS  451 

To  this  treatment  there  should  be  added  the  routine  technic  of  continuous  colon 
irrigation  which  has  given  admirable  results  ia  the  hands  of  Prof.  John  B. 
Murphy  ^ :  "  The  vaginal  hard-rubber  tube  of  an  ordinary  fountaia  syringe  is  heated 
and  bent  two  and  a  half  inches  from  the  end  at  an  angle  of  about  thirty-five  degrees 
and  inserted  into  the  rectum.  To  this  is  attached  a  rubber  tube  secured  to  the  side 
of  the  thigh  by  adhesive  straps  so  as  to  prevent  its  possible  displacement.  A  foun- 
taia s^Tinge  filled  with  normal  salt  solution,  and  kept  at  a  temperature  of  about 
100°  F..  with  an  elevation  of  from  six  to  eighteen  inches,  as  required,  should  be 
allowed  to  flow  in  until  from  one  and  a  half  to  three  pints  have  been  taken.  The 
influx  of  this  solution  should  be  very  slow,  requiring  at  least  sixty  minutes  for  the 
quantity  above  given,  the  inflow  to  be  controlled  by  the  elevation  of  the  s\Tinge  and 
never  by  a  forceps  applied  to  the  tube  to  lessen  its  lumen,  as  this  will  prevent  a 
rapid  return  of  flow  to  the  can,  or  the  escape  of  gas  should  the  patient  cough  or 
strain.  The  quantitj^  should  be  repeated  everj'  two  hours.  Xever  remove  the  rectal 
tube,  except  for  defecation.  AVhen  it  is  not  retained,  it  is  improperly  given."  Pro- 
fessor Murphy  has  succeeded  in  having  a  child  retain  and  absorb  as  much  as  thirty 
pints  in  thirty-four  hours.  By  this  treatment  it  is  intended  to  tide  the  patient 
over  the  immediate  effects  of  toxaemia.  Should  emesis  or  gastric  distention  be 
present,  lavage  of  the  stomach  will  give  great  relief. 

In  a  certain  proportion  of  these  cases  of  general  peritonitis  secondary  pus 
pockets  will  form,  and  require  to  be  opened.  Obstructions  due  to  adhesions,  and 
ileus  caused  by  partial  intestinal  paralysis,  are  not  infrequently  encountered. 

TubercuJou.s  peritoniiis  results  from  the  lodgment  in  this  membrane  of  the 
lacilli  tuberculosis.  These  may  be  carried  through  the  vessels  and  be  generally 
disseminated  (miliary),  or  the  infection  may  be  by  direct  invasion  from  an  in- 
fected focus  in  any  of  the  organs  with  which  the  peritoneum  is  in  contact.  It  is 
most  frequently  observed  from  the  twentieth  to  the  fortieth  year  of  life,  although 
about  eighteen  per  cent  of  all  cases  occur  in  children.  Women  are  affected  more 
than  men  in  the  proportion  of  2  to  1.  Clinically  it  exists  in  two  forms,  the  moist 
(or  ascitic)  and  the  dry  (fibroplastic  or  adliesive).  In  the  former  the  peritoneal 
surface  is  studded  with  minute  tubercular  nodules,  which  may  be  localized  or 
generallj^  disseminated.  Transudation  of  serum  is  a  feature  of  this  form,  and  the 
quantity  of  liquid  is  generally  proportionate  to  the  area  involved.  Occasionally 
the  transudate  Ijecomes  encysted  in  one  or  more  separate  cavities. 

In  the  fibroplastic  variety  there  is  little  or  no  serous  effusion,  but  an  exudate, 
in  the  presence  of  which  the  mesentery,  omentum,  and  intestines  become  agglu- 
tinated. 

An  ulcerated  form  has  also  been  described,  but  this  is  nothing  more  than  a 
cheesy  degeneration  of  the  tuberculous  nodules. 

The  symptoms  of  tuberculous  peritonitis  are  not  well  marked  in  the  early 
stages.  It  is  not  a  painful  disease.  There  is  the  disturbance  of  nutrition  charac- 
teristic of  tuberculosis  in  other  organs.  Usually  the  first  symptom  of  the  moist 
form  is  a  collection  of  fluid  in  the  pelvis  and  lower  portion  of  the  abdominal  cavity. 
In  the  dry  variety  the  agglutination  of  the  viscera  may  be  recognized  by  careful 
palpation. 

The  treatment  is  medical  and  surgical.  Tonics,  the  open-air  treatment,  and 
careful  nutrition  are  essential  in  all  cases,  and  must  be  practically  relied  upon  in 
the  miliary  form,  in  which  there  is  apt  to  be  a  general  dissemination. 

As  far  as  operative  intervention  is  concerned,  the  best  results  have  been  obtained 
in  tuberculous  peritonitis  with  transudation  resulting  from  limited  infection.  The 
operation  consists  in  a  small  incision  near  the  median  line,  splitting  the  rectus 
muscle.  Irrigation  with  saline  solution  (110°-115°  F.)  may  be  added,  using  by 
preference  the  Blake  tube,  the  excess  of  liquid  being  permitted  to  remain  in  the 
general  cavit\^  Xo  handling  of  the  viscera  should  be  permitted,  and  the  abdominal 
wound  should  be  immediateh"  closed  without  drainage. 

1  Professor  Murphj'  also  recommends  "  10  to  20  c.  c.  of  Steam's  streptolji:ic  spnim  every 
twelve  hom-s  mitil  from  two  to  six  doses  have  been  given,  depending  on  the  conditions."  In  the 
present  status  of  serum  therapy  the  purity  of  the  agent  injected  should  be  assvired. 


CHAPTEE    XXV 


A  HERNIA  is  formed  by  the  protrusion  of  a  iDortion  or  all  of  any  visens  from 
its  normal  cavity.  Although  there  may  be  a  hernia  of  the  brain,  lung,  bladder, 
spleen,  etc.,  the  term  by  common  consent  is  almost  wholly  restricted  to  protru- 
sions of  intestine  (enterocele),  or  omentum  (epiplocele),  or  both. 

Hernia  may  be  congenital  (when  it  exists  in  utero  or  at  birth)  or  it  may  be 
acquired. 

It  is  termed  complete  when  the  organ  escapes  entirely  through  the  substance 
of  the  enclosing  wall;  incomplete  when  it  has  entered  and  has  not  yet  escaped. 
A  hernia  is  reducible  when  the  contents  of  the  sac  can  be  returned  to  the  peri- 
toneal cavity,  irreducihle  when  this  cannot  be  accomplished,  and  strangulated 
when  the  circulation  in  its  contents  is  wholly  or  partially  arrested  by  constriction 
(usually  at  the  neck). 

Ilernice  are  classified  according  to  their  place  of  escape:  inguinal,  femoral, 
timbilical,  ventral,  diaphragmatic,  gluteal,  obturator,  lunibar,  vaginal,  pudendal, 
and  perineal.  The  term  vetitral  is  applied  to  all  hernia;  occurring  at  points  on  the 
abdominal  wall  other  than  those  indicated  in  the  classification  just  given.  Of 
hernife  in  general,  the  inguinal  variety  forms  about  eighty  per  cent  of  all  cases; 
femoral,  ten;  umbilical,  five;  the  remaining  varieties,  five.  Of  every  five  patients 
affected  with  hernia  four  are  males.  Inguinal  hernia  in  males  occurs  more  often 
in  the  first  ten  years  of  life  than  in  any  subsequent  decade,  the  period  from  the  twen- 
tieth to  the  fortieth  year  being  next  in  order  of  frequency.  According  to  Kingdon, 
femoral  hernia  in  males  of  all  ages  is  met  with  in  four  of  every  hundred  cases;  in 
the  first  decade  in  one  of  every  three  hundred,  in  the  second  two  per  cent;  in  the 
third  and  fourth  together,  four  and  a  half  per  cent;  the  fifth  and  sixth,  six  per 
cent;  and  after  this,  eight  per  cent.  In  females  inguinal  and  femoral  herniae  are 
met  with  in  about  equal  proportions.  The  latter  variety  is  rarely  met  with  before 
puberty,  but  occurs  chiefly  during  the  child-bearing  period    (Thomas  Bryant). 

Structure  of  Hernia 

The  contents  of  the  hernia  are  enclosed  in  a  sac,  almost  always  formed  by  the 
peritonaeum  lining  the  abdominal  cavity.  The  sac  may  be  carried  immediately  in 
front  of  the  escajDing  intestine  or  omentum  (femoral,  umbilical,  etc.),  or  these 
viscera  may  descend  into  a  sac  already  formed  by  the  escape  of  some  other  organ, 
as  the  testicle  (inguinal,  scrotal).  In  the  rare  cases  of  hernia  of  those  portions 
of  the  large  intestine  not  covered  by  peritonfeum  there  is  no  true  sac.  That  part 
of  the  sac  which  looks  directly  into  the  abdominal  cavity  is  called  the  mouth,  the 
constricted  portion  between  this  and  the  main  cavity  or  body  is  the  nech,  while 
the  deepest  or  most  protruding  j)ortion  is  the  fundus. 

The  sac  varies  in  thickness  generally  in  proportion  to  the  age  of  the  hernia. 
In  a  recent  hernia  it  is  exceedingly  thin,  while  in  some  forms  of  scrotal  hernia, 
of  long  duration,  it  may  be  as  much  as  one  sixteenth  or  one  eighth  of  an  inch 
in  thickness. 

Special  Hernia 

Inguinal  Hernia. — ^An  inguinal  hernia  may  be  direct  or  indirect,  complete 
or  incomplete,  congenital  or  acquired.     The  indirect  or  "  oblique  "  variety  is  much 

452 


HERXO. 


453 


more  frequently  met  -vrith.  In  the  male,  the  contents  pass  into  the  internal  ah- 
dominal  ring,  and  follow  the  spermatic  cord  along  the  inguinal  canal,  at  times 
descending  into  the  tunica  vaginalis  testis.  In  the  female,  the  descent  is  in  the 
canal  of  iSTuck,  following  the  round  ligament  in  the  inguinal  canal,  and  at  times 
as  far  as  the  labium.  The  epigastric  vessels  are  internal  to  the  neclc  and  behind 
the  iody  of  an  oblique  inguinal  hernia  (1,  Fig.  il5,  and  Fig.  475  b). 

A  direct  hernia  does  not  enter  the  internal  abdominal  ring,  but  pushes  the 
fascia  which  is  to  the  inner  side  of  the  epigastric  vessels  and  immediately  behind 
the  external  ring  directly  in  front  of  the  tumor  and  out  at  the  external  ring. 

Therefore  the  epigastric  vessels  are  external  to  the  nech,  and  may  be  displaced 
slightly  in  front  and  to  the  outer  side  of  a  direct  inguinal  hernia  {2,  Fig.  475, 
and  Fig.  475  a). 

An  inguinal  hernia  is  said  to  be  complete  when  the  contents  protrude  beyond 
the  external  ring;  incomplete  when  the  tumor  is  within  this  limit.     A  complete 


Fig.  475. — The  relations  of  the  points  of  escape  of  oblique  and  direct  inguinal  and  obturator  hemife  to  the 
important  vessels  of  the  peh-is.  1,  Internal  abdominal  ring.  2,  Point  at  which  a  direct  inguinal 
hernia  commences.  3.  Obtiu-ator  canal,  arter\-,  and  ner\-e.  The  epigastric  vessels  are  seen  passing 
upward  between  1  and  2.      (Modified  from^  ilaclise.) 


inguinal  hernia  in  the  male  may  descend  into  the  cavitj"  of  the  tunica  vaginalis 
testis,  the  contents  resting  in  contact  with  the  testicle  {congenital)  (Fig.  476), 
or  it  may  be  arrested  in  the  tubular  sheath  which  surrounds  the  spermatic  cord 
{infantile) ,  the  contents  not  in  contact  with,  but  pressing  upon,  the  testicle  (Fig. 
477). 

There  is  a  rarer  form  of  inguinal  hernia,  known  as  the  encysted  hernia  of 
Astley  Cooper.  This  variet}^  of  hernia  is  produced  as  follows :  The  vaginal  process 
on  that  part  of  the  peritoneal  pouch  which  surrounds  the  spermatic  cord  from 
the  internal  to  the  external  rins.  and  which  normallv  is  closelv  adherent  to  the 


•-3  c 


g  MM 
o'S.      ^ 

°     §f 


s  s  s  s 


■S  C3  fi  3 

03  W   53  O 


2t)  (B-3 


454 


HERNIA 


455 


cord,  not  permitting  the  entrance  of  any  of  the  abdominal  contents,  is  closed  at 
the  internal,  but  remains  unclosed  at  the  external  ring.  The  hernia  descending, 
pushes  before  it  the  parietal  peritonjeum  as  in  ordinary  hernia,  and  carries  it 
gradually  do^^Tiward  until  it  is  protruded  into  the  unclosed  vaginal  process  below, 
forming  in  this  way  two  sacs. 

Inguino-properitoncal  Hernia. — A.  E.  Halstead  ^  describes  inguino-properi- 
toneal  hernia  as  "  containing  two  sacs,  or  two  divisions  of  one  sac,  the  inner  or 
intraparietal  sac  lying  between  the  peritonaeum  and  the  transversalis  fascia,  and 


Pig.  476. — Cuiiiriniial  Mbli(.|ue  inguinal  hernia. 
Sac  formed  by  the  tunica  vaginalis  et  funi- 
culi. 1,  Cavity  of  the  tunica.  (After  Mac- 
lise.) 


Fig  477  — Infantile  hernia  (acquired),  the  intes- 
tine carrying  with  it  a  process  of  peritonseum 
by  the  side  of  the  occluded  spermatic  tube. 
(After  Maclise.) 


the  outer  or  inguinal  sac,  which  occupies  the  inguinal  canal  or  extends  down  into 
the  scrotum  for  a  variable  distance.  The  origin  of  the  two  sacs  is  by  a  common 
funnel-like  process." 

In  addition  to  this  type,  there  is  a  form  of  interstitial  hernia  found 'at  times 
hetween  the  internal  oblique  and  the  aponeurosis  of  the  external  oblique  muscle, 
or  the  preperitoneal  sac  maj'  lie  between  the  skin  and  the  external  oblique. 

It  will  be  seen  that  an  oblique  inguinal  hernia  is  congenital  when  it  follows 
■exactly  in  the  route  traveled  by  the  testicle  in  its  descent  and  lies  in  contact  with 
this  organ.  This  form  of  hernia  exists  generally  at  birth,  but  it  has  been  known 
to  occur  after  birth  and  even  in  adiilt  life  in  rare  instances  where  the  vaginal 
process  and  tunica  funiculi  have  not  firmly  united  and  are  easily  broken  through. 

In  an  infantile  hernia,  which  occurs,  as  its  name  implies,  usually  soon  after 
birth,  but  which  may  also,  in  exceptional  instances,  occur  later  in  life,  the  intes- 
tine descends  along  the  tubular  sheath  which  surrounds  the  spermatic  cord,  but 
finds  this  sheath  closely  attached  to  the  cord  at  the  upper  margin  of  the  testicle, 

1  This  observer  reports  that  "  after  exposing  the  external  abdominal  ring  a  sac  was  found  ex- 
tending from  the  ring  down  into  the  scrotum.  This  %Yas  freed  from  its  attachments  up  to  the 
external  ring.  The  inguinal  canal  was  opened  by  incising  the  aponeurosis  of  the  external  oblique. 
After  freeing  the  inguinal  sac  up  to  the  internal  ring  it  was  opened,  and  from  it  escaped  a  small 
quantity  of  bloody  serum.  On  pulling  do-mi  on  the  inguinal  .sac,  the  neck  of  a  second  sac  was 
brought  into  view.  This  sac  was  opened  by  extending  the  incision  made  in  the  first  sac.  It  was 
seen  to  contain  a  small  knuckle  of  the  small  intestine  and  a  piece  of  omentum." — "Annals  of 
Surgery,"  May,  1906. 


456 


HERNIA 


where  it  is  arrested;  and  while  by  its  weight  it  may  descend  into  the  scrotum  and 
2jass  beyond  the  level  of  the  testicle,  it  never  lies  in  contact  with  it,  as  in  the 
ease  of  congenital  oblique  inguinal  hernia.  In  general,  therefore,  we  may  say  that 
an  inguinal  hernia  is  congenital  or  acquired,  the  congenital  form  existing  at  birth, 

while  the  acquired  hernia  (Fig.  478) 
fc^         -  is  one  which  comes  on  after  birth, 

and  is  caused  chiefly  by  the  pressure 
of  the  intestine  or  omentiam.  from 
gravity  and  muscular  effort  com- 
loined. 

Femoeal  Heknia. — This  is  al- 
ways an  acquired  hernia.  The  tu- 
mor enters  the  femoral  or  crural 
canal  (1,  Pig.  479)  beneath  Pou- 
part's  ligament  just  to  the  inner 
side  of  the  iliac  and  femoral  vein.- 
If  it  remains  in  the  crural  sheath 
it  is  an  incomplete,  but  if  it  pro- 
trudes at  the  saphenous  opening 
(Fig.  480)  it  is  a  complete  femoral 
hernia. 

Umbilical  Hernia. — Umbilical 
hernia  is  either  congenital  or  ac- 
quired. It  exists  not  infrequently 
at  birth  in  both  sexes  on  account 
of  the  patulous  condition  of  the 
omphalo-niesenteric  duct.  In  this 
variety  the  only  covering  of  the 
tumor  is  the  sheath  of  the  umbili- 
cal cord.  In  the  acquired  form 
the  intestine  escapes  either  directly 
through  the  navel  or  more  fre- 
quently to  one  side  of  this  con- 
traction. The  sac  of  an  acquired 
umbilical  hernia  is  composed  of  the 
parietal  layer  of  the  peritoncewm,  and  the  outer  covering  of  integument  and  sub- 
cutaneous fat. 

Ventral  Hernia.- — This  may  also  be  congenital  or  acquired.  The  protrusion 
may  occur  at  birth  as  a  result  of  failure  of  development  in  the  muscles  of  the 
abdomen.  It  is  usually  met  with  along  the  linea  alba  above  the  umbilicus.  The 
acquired  form  may  occur  at  any  point,  and  results  from  accidental  or  surgical 
wounds  of  the  muscles  and  fascia  and  occasionally  from  pregnancy.  It  is  quite 
frequently  met  with  in  the  wounds  of  incision  in  laparotomy. 


Fig.  478. — Complete  (acquired)  inguinal  hernia  as  it 
occurs  in  the  adult.  Not  communicating  witli  the 
cavity  of  the  tunica  vaginalis  testis.    (After  Maclise.) 


Eaeek  Forms  of  Hernia 

Diaphragmatic  hernia  is  usually  due  to  a  wound  or  rupture  of  the  diaphragm. 
It  may  result  from  a  congenital  defect  in  this  muscle.  It  generally  occurs  on  the 
left  side  on  account  of  the  protection  afforded  by  the  liver  on  the  right  side.  The 
intestine  or  stomach  may  be  imprisoned. 

Gluteal  hernia  is  extremely  rare.  The  escape  of  the  viscus  is  through  the 
sciatic  notch,  and  it  may  occur  above  or  below  the  pyriformis  muscle. 

Obturator  hernia  takes  place  in  the  thyroid  (obturator)  foramen,  usually  in 
the  upper  portion  of  the  canal  which  gives  exit  to  the  obturator  vessels  and  nerves 
(3,  Fig.  475).     It  is  more  common  in  women  than  in  men. 

Lumbar  hernia  occurs  in  the  region  situated  between  the  twelfth  rib  and  the 
crest  of  the  ilium. 

Hernia  into  the  vagina  occurs  as  a  rule  with  partial  or  complete  prolapse  of 
the  uterus,  or  after  loss  of  substance  allowing  escape  of  the  intestine. 


Hii 


458 


HERNIA 


Penned  hernia  descends  to  one  side  of  the  median  line  of  the  perinseum 
between  the  bladder  and  the  rectum  in  the  male;  between  the  rectum  and  tlie 
vagina  in  the  female,  traveling  along  the  inner  slope  of  the  levator  ani  muscle.  It 
is  extremely  rare,  but  has  been  known  to  follow  the  operation  of  lithotomy. 

Pudendal  hernia,  in  which  the  bowel  passes  down  between  the  ramus  of  the 
ischium,  and  the  vagina,  forming  a  tumor  in  the  labium,  and  sacro-rectal  hernia, 
which  is  described  as  having  occurred  in  failure  of  the  junction  by  ossification 
of  the  separate  bones  composing  the  .sacrum,  are  rarely  observed. 

There  is  also  at  times  a  hernia  of  the  ovary  into  the  canal  of  Nuek,  and  there 
are  two  instances  on  record  in  which  a  hernia  of  the  Fallopian  tube  alone  existed 
in  this  canal.  One  of  these  cases  was  in  the  practice  of  the  author,  and,  having 
become  strangulated,  caused  the  death  of  the  woman  by  infectious  peritonitis, 
the  infection  spreading  through  the  disintegrating  sac  into  the  peritoneal  cavity. 
The  bladder  has  also  Ijeen  known  to  protrude  into  the  inguinal  canal  and  through 
the  external  ring,  the  author  having  observed  several  cases. 

Symptoms,  Diagnosis,  and  Teeatment  of  Hernia 

Symptoms  and  Diagnosis  of  Inguinal  Hernia. — When  gradually  acquired,  the 
presence  of  a  small  swelling  or  tumor  near  the  center  of  Poupart's  ligament,  or 
a  little  to  the  inner  side  of  this  point,  is  usually  the  first  symptom  of  inguinal 
hernia.  In  a  certain  proportion  of  cases  the  appearance  of  the  swelling  has  been 
preceded  by  a  feeling  of  weakness  or  uneasiness  referred  to  this  region,  which  only 
disappeared  when  the  recumbent  posture  was  assumed,  or  when  strong  upward 
pressure  was  made  by  the  hand. 

If  suddenly  acquired,  the  presence  of  the  tumor  is  noticed  soon  after  a  vio- 
lent strain  of  the  abdominal  muscles.  Pain  is  almost  always  present,  and  the 
patient  is  generally  aware  that  rupture  has  occurred. 

The  diagnosis  of  inguinal  hernia  involves  (1)  the  differentiation  between  the 
direct  and  indirect  variety,' and  (2)  between  inguinal  and  femoral  hernise  and  the 
various  swellings  which  may  occur  in  this  region:  varicocele,  hydrocele,  bubo, 
incarcerated  testicle,  ovary,  cyst.  Fallopian  tube,  new  formations,  abscess,  and 
aneurism. 

A  direct  inguinal  hernia  is  exceptional.  The  tumor  formed  by  it  is  apt  to 
be  spherical  (Fig.  481),  is  situated  nearer  the  median  line,  and  the  neck  ^dll 
be  found  to  enter  the  abdominal  cavity   immediately  behind   the   external  ring. 


Fig.  481. — Direct  inguinal  hernia. 
(After  Thomas  Bryant.) 


Fig.  482. — Incomplete  oblique  inguinal 
hernia.      (After  Thomas  Bryant.) 


The  tumor  formed  by  an  oblique  inguinal  hernia  is  oval  or  elliptical  in  the 
incomplete  (Fig.  482)  and  oval  or  pyriform  in  the  complete  variety.  The  history 
of  the  swelling,  if  gradually  developed,  will  indicate  that  the  tumor  commenced 
at  the  middle  of  Poupart's  ligament  and  traveled  toward  the  pubes.  In  cases  of 
long  standing,  and  wlicn  the  tumor  is  of  large  size,  the  diagTiosis  between  the 


HERNIA  459 

direct  and  indirect  form  is  scarcely  possible,  from  the  fact  that  the  inner  edge  of 
the  internal  ring  has  been  dragged  down  until  it  occupies  a  position  just  behind 
the  external  opening. 

A  femoral  hernia  is  situated  below  Poupart's  ligament,  and  near  its  attach- 
ment to  the  spine  of  the  pubes,  to  the  inner  side  of  the  femoral  vessels  (Fig.  483). 
In  lean  subjects  the  neck  of  the  tumor  can  be  readily 
traced  to  the  canal  at  this  point.     In  corpulent  jJcr-  ^^ 

sons  the  diagnosis  is  more  difficult.  T 

The  swelling  of  varicocele  commences  in  tlie  lower        / 
250sterior  23ortion  of  the  cord  and  increases  gradually       / 
upward.     To  the  touch  the  distended  veins  feel  like      / 
worms.    The  tumor  has  none  of  the  elasticity  of  her-      / 
nia.     In  the  recumbent  posture  a  varicocele  and  a      I 
non-incarcerated  inguinal  hernia  will  both  disappear.      | 
If  after  the  disappearance  firm  pressure  is  made  with       \- 
tiie  fingers,  and  the  patient  is  directed  to  resume  the       ^ 

upright  posture,  the  varicocele,  despite  the  pressure,     yig.  4S3. Femoral  hernia.  (After 

will  return,  while  the  hernia  cannot  descend.   Cough-  Thomas  Bryant.)  '^ 

ing  does  not  give  an  impulse  to  varicocele. 

The  accumulation  of  fluid  in  hydrocele  of  the  tunica  vaginalis  is  first  noticed 
in  the  most  inferior  portion  of  the  scrotiim ;  the  swelling  is  spherical  at  first,  and 
becomes  pyriform  after  the  cord  is  involved.  Hydrocele  is  translucent,  and  fluc- 
tuation may  be  detected.  Encysted  hydrocele  of  the  cord  near  the  external  ring 
or  within  the  inguinal  canal  may  make  differentiation  more  difficult.  The  im- 
pulse from  coughing  is  not  marked  in  hydrocele,  the  sense  of  weakness  is  absent, 
the  cyst  is  small,  and  usually  remains  so.  If,  after  full  consideration,  doubt  still 
exists,  aseptic  aspiration  with  the  finest  hypodermic  needle  will  clear  up  the  diag- 
nosis without  danger. 

Bubo. — In  chronic  adenitis  the  glandular  character  of  the  swelling  can  be 
made  out  distinctly.  In  acute  adenitis,  although  the  perilymidiatic  infiltration 
is  so  extensive  that  the  glands  cannot  be  recognized,  the  redness  of  the  skin,  the 
great  tenderness  on  pressure,  and  the  superficial  character  of  the  pain,  with  the 
coexistence  of  a  urethritis  or  sore  upon  the  penis  or  scrotum,  will  serve  to  estab- 
lish the  character  of  the  lesion. 

Incarcerated  testicle  may  be  suspected  if  there  is  absence  of  the  organ  on  that 
side.  If  the  testicle  is  not  extensively  atrophied,  pressure  will  give  the  peculiar 
and  characteristic  sense  of  pain  experienced  in  injury  of  this  organ. 

In  neoplasms  there  is  a  history  of  progressive  development  entirely  disasso- 
ciated from  that  of  hernia,  as  heretofore  detailed.  Incarceration,  temporar}^  or 
permanent,  of  an  ovary  in  the  canal  of  jSTuck  may  be  suspected  when  on  coughing 
there  is  no  marked  impulse  to  the  tumor,  and  when  pain  is  increased  coexistent 
with  the  menstrual  period.  Cysts  of  the  canal  of  ISTuck  or  of  the  inguinal  canal 
are  rare,  but  have  been  met  with  in  a  number  of  cases — four  or  five  within  the 
experience  of  the  author.  They  differ  from  hernije  in  general  since  they  are  irre- 
ducible, and  do  not  impart  well-marked  impulse  on  coughing. 

Alisccss,  which  not  infrequently  appears  above  Poupart's  ligament,  is  accom- 
panied with  inflammatory  and  septic  symptoms  which  do  not  accompany  hernia. 
Abscess  of  this  region  occurs  with  adenitis,  as  just  stated,  and  with  osteitis  of 
the  vertebrje  or  ilium.  The  recognition  of  either  of  these  lesions  will  lead  to  the 
diagnosis  of  abscess. 

In  the  manipulation  of  a  hernial  tumor,  the  sensation  imparted  to  the  fingers 
will  vary  with  the  contents  of  the  sac  and  the  condition  of  the  mass.  If  it  contain 
only  omentum,  it  is  doughy  to  the  feel,  and  will  yield  dullness  on  percussion. 
If  the  mass  is  composed  of  intestine,  it  is  elastic  and  more  or  less  tympanitic  on 
percussion.  The  "  colicky  "  pain  felt  when  the  intestine  is  firmly  compressed  is  of 
diagnostic  value  in  determining  the  contents  of  a  hernia.  AVhether  a  hernia  is 
reducible  or  not,  there  is  always  a  perceptible  impulse  imparted  to  the  tumor  in 
•coughing  or  sneezing.  In  strangidated  hernia  the  diganosis  rests  first  upon  the 
■existence  of  a  swelling,  which  is  present  in  almost  all  cases.     In  very  exceptional 


460  HERNIA 

instances  there  is  no  protrusion  noticeable.  The  next  symptom  is  pain  at  the 
seat  of  the  hernia.  In  character  it  is  compared  to  that  of  intestinal  colic,  and 
when  not  intensified  at  the  point  of  strangulation  it  is  usually  referred  to  the 
umbilical  region.  The  symptoms  of  occlusion  are  more  remote,  and  ^yhile  very 
strong  in  a  diagnostic  point  of  view,  are  practically  not  of  much  importance,  be- 
cause a  diagnosis  should  be  made  and  treatment  instituted  before  the  effects  of 
obstruction  are  made  evident.  The  cessation  of  fecal  discharges  may  not  occur 
in  intestinal  obstruction  for  several  days  after  the  occlusion,  when  the  small  intes- 
tine alone  is  involved,  since  the  contents  of  the  bowel  below  the  constricted  point 
may  be  evacuated.  The  vomiting  of  recently  ingested  food  or  drinks  followed  by 
stercoraceous  matter  is  the  last  and  strongest  evidence  of  occlusion.  Distention 
of  the  abdominal  walls,  with  tympanitic  resonance,  is,  when  taken  in  connection 
with  other  symptoms,  a  strong  link  in  the  chain  which  makes  the  diagnosis  con- 
clusive. Hiccough  is  present  in  many  cases,  but  is  apt  to  be  one  of  the  later 
evidences  of  obstruction.  Shock  is  present  in  a  varying  degree  in  almost  all  cases 
of  strangulated  hernia.  It  is  evident  in  a  rapid  and  weak  pulse,  occasionally 
missing  a  beat,  or  varying  in  exacerbations  of  rapidity  and  slowness;  coldness  of 
the  skin  with  unnatural  perspiration,  lack  of  facial  mobility,  the  eyes  wide  open 
and  staring,  the  only  expression  being  that  of  pain  or  great  anxiety.  In  omental 
hernia  the  pain  is  not  so  intense  as  in  intestinal  hernia,  and  the  symptoms  of 
occlusion  are  always  absent. 

The  treatment  of  inguinal  hernia  may  be  considered  under  the  following  heads : 
(1)  the  reducible,  (2)  the  non-reducible  (not  strangulated),  (3)  the  strangulated. 

A  reducible  inguinal  hernia  should  be  returned  to  the  abdominal  cavity  and  re- 
tained within  by  a  carefully  adjusted  truss  or  bandage  and  compress.  Eeduction 
is  accomplished  by  placing  the  patient  upon  the  back  in  the  more  or  less  com- 
plete Trendelenburg  posture,  with  the  thighs  flexed  upon  the  abdomen.  If,  after 
a  few  minutes,  gravitation  does  not  accomplish  reduction,  gentle  pressure  with 
the  fingers  should  suffice.  Overmanipulation  of  the  hernia  {taxis)  is  not  ad- 
vised. The  retention  apparatus  should  be  applied  while  resting  on  the  back.  If 
a  truss  is  to  be  worn  the  patient  should  be  carefully  instructed  as  to  its  proper 
use.  It  should  never  be  applied  unless  the  inguinal  canal  is  entirely  empty,  and 
the  pressure  should  be  only  strong  enough  to  close  the  canal.  Overpressure  does 
harm,  especially  to  the  spermatic  cord  in  males,  and  in  both  sexes  by  causing 
atrophy  in  the  underlying  muscles.  Among  the  trusses,  which  for  incipient  her- 
nia are  worn  with  the  minimum  degree  of  discomfort,  is  some  form  of  an  elastic 
belt  with  a  firm  pad,  held  accurately  in  place  by  a  perineal  strap.  The  spiral 
spring  truss,  which  has  no  perineal  band,  is  preferred  by  some.  In  measuring. 
for  a  truss,  or  in  sending  an  order  to  a  maker,  the  character  of  the  hernia  shoidd 
be  described  and  accurate  measurements  given.  One  end  of  a  lead  tape  should 
be  laid  directly  over  the  internal  ring  and  carried  across  the  abdomen  to  just  below 
the  anterior  superior  spine  of  the  ilium,  thence  across  the  gluteal  region  to  the 
same  point  below  the  anterior  superior  spinous  process  of  the  affected  side.  The 
malleable  lead  should  be  pressed  closely  to  the  skin  in  order  to  get  an  exact  out- 
line of  the  surface  to  which  the  truss  is  to  be  applied,  and  this  should  be  imme- 
diately traced  upon  paper.     In  bilateral  hernia  a  double  truss  should  be  worn. 

An  emergency  support  may  be  made  as  follows :  A  bit  of  soft  cloth,  cotton, 
wool,  or  oakum  is  made  into  a  ball  three  inches  in  diameter,  covered  with  adhe- 
sive plaster  (adhesive  surface  outward),  and  laid  immediately  over  the  inguinal 
canal  as  the  patient  is  recumbent.  A  figure-of-8  spica  soft  flannel  bandage  is 
carried  around  the  pelvis  and  thigh,  holding  the  compress  firmly  in  position.  The 
adhesive  plaster  covering  adheres  to  the  skin  and  spica.  When  plaster  is  not  at 
hand  safety  pins  may  be  used  to  fix  the  compress  to  the  bandage. 

The  operation  for  the  cure  of  all  forms  of  hernife  (and  especially  inguinal)  is 
now  so  free  from  danger  and  results  in  such  a  large  proportion  of  cures  that  the 
vast  majority  of  those  afflicted  should  be  advised  to  submit  to  it  at  once.  Beyond 
the  annoyance  of  a  truss,  the  ever  present  danger  of  strangulation,  especially  to 
those  not  within  two  or  three  hours'  reach  of  an  experienced  surgeon,  fully  justifies 
this  conclusion,  and  now  that  very  many  of  these  operations,  where  the  tumor 


HERNIA  461 

is  not  so  large  as  to  necessitate  a  long  and  extensive  dissection,  may  be  success- 
fully done  with  the  analgesia  of  quinia  and  urea  or  cocaine,  the  proportion  of 
persons  requiring  trusses  should  year  by  year,  as  the  lait}^  learns  this  important 
lesson,  become  smaller. 

RADICAL    CUBE    OF    OBLIQUE    IXGUIXAL    HEEXIA THE    OPEEATIOX    OF     CHOICE 

Asepsis  is  so  essential  that  the  minutest  details  should  be  carried  out.  All 
parts  in  and  about  the  field  of  operation  should  be  thoroughly  shaved  (see  prepa- 
ration of  patient),  scrubbed,  asepticized,  protected  from  subsequent  exposure 
twelve  hours  before  the  operation,  and  this  repeated  upon  the  table.  In  males  a 
sterilized  rubber  bag  should  envelope  the  penis  and  scrotum  or  (not  having  this) 
rubber  tissue  or  gauze  should  isolate  these  organs. 

Locate  with  the  index-finger  the  external  ring,  and  especially  its  upper  border. 
An  incision,  three  inches  long  (to  be  lengthened  if  necessary)  through  the  skin 
and  superficial  fat  down  to  the  aponeurosis  of  the  external  oblique  muscle  is 
made,  commencing  at  the  suprapubic  skin  fold,  just  above  the  center  of  the  upper 
margin  of  the  external  abdominal  ring,  thence  obliquely  upward  and  outward 
toward  a  point  about  two  inches  internal  to  the  anterior  iliac  spine.  Below  this 
level  is  a  rich  plexus  of  vessels  which  are  thus  avoided,  while  traction  downward 
from  the  lower  angle  of  the  incision  will  thorouglily  expose  the  external  ring 
(and  cord).  The  upper  border  of  the  external  ring  should  be  divided  with  dull- 
pointed  scissors  near  the  internal  pillar,  the  object  being  to  leave  as  much  of 
an  outer  aponeurotic  flap  as  possible,'-  The  aponeurosis  is  carefully  split  between 
two  parallel  fibers  to  a  point  sufficiently  high  in  the  line  of  incision  to  expose  the 
internal  ring,  the  arched  fibers  of  the  internal  oblique  and  transversalis  muscles, 
the  conjoined  tendon,  and  the  neck  of  the  sac.  With  the  dull-pointed  scissors  the 
aponeurosis  of  the  external  oblique  is  separated  from  the  underhing  tissues  until 
its  reflected  portion  (Pouparfs  ligament)  is  clearly  exposed,  while  the  inner 
flap  is  also  lifted  an  inch.  This  being  done  and  all  bleeding  arrested,  the  in- 
guinal nerve  vrill  be  seen  and  should  be  carefully  avoided." 

The  structures  of  the  spermatic  cord  should  be  carefully  separated  from  the 
hernial  sac  with  the  blunt-pointed  half-curved  scissors.  Should  adhesions  have 
formed,  the  cord  may  be  recognized  by  the  peculiar  shoestring  feel  of  the  vas 
deferens,  its  white  appearance,  and  the  vence-comites.  In  separating  the  sac  from 
the  cord,  care  should  be  taken  not  to  draw  heavily  upon  the  latter,  and  this  is 
especially  important  in  children.  The  sac  of  the  hernia  should  be  thorouglfly 
freed  in  its  entire  circumference  from  aU  adhesions  down  to  the  internal  ring 
and  as  far  as  the  level  of  the  peritoneum  lining  the  abdominal  wall.  Immedi- 
ately above  the  arch  of  the  internal  ring  the  peritonseum  should  be  fiuther  sepa- 
rated from  the  muscles  by  the  end  of  the  index-finger  until  an  extra-peritoneal 
pocket  is  formed  as  shown  in  Fig.  484.  .The  hernial  sac  should  now  be  care- 
fully opened,  the  finger  introduced,  and  the  contents  reduced.  The  index-finger 
should  be  carried  the  entire  circumference  of  the  neck  of  the  sac  upon  the  peri- 
toneal surface  to  demonstrate  the  absence  of  adhesions.  These,  if  present,  shoidd 
be  carefully  separated.    When  omentum  forms  a  portion  or  aU  of  the  hernial  con- 

•  It  is  not  always  necessary  to  di^^de  this  ring.  The  aponeurosis  of  the  external  oblique 
may  be  split  to  within  one  half  inch  of  it  and  the  outer  portion  retracted  sufficiently  to  expose 
Poupart's  ligament. 

^  The  hypogastric  branch  perforates  the  external  obUque  above  the  external  abdominal  ring, 
to  be  distributed  to  the  integument  of  this  region.  It  is  the  least  important  of  the  nerves  which 
come  into  the  field  of  operation,  and  no  very  serious  results  foUow  its  di^-isiou.  It  should  not  be 
forgotten,  however,  that  this  nerve  sometimes  takes  the  place  of  the  inguinal  branch  of  the  ilio- 
inguinal, and  that  the  later  is  occasionally  absent.  It  is  always  important  to  be  on  the  lookout 
for  all  of  these  nerves,  and  to  avoid  them  if  possible. 

The  inguinal  branch  of  the  ilio-inguinal  pierces  the  internal  oblique  above  the  inner  ring, 
distributing  filaments  to  the  muscles,  and  in  males  accompanies  the  spermatic  cord  to  escape  at 
the  external  abdominal  ring  to  be  distributed  to  the  internal  surface  of  the  scrotal  or  labial  regions. 
The  genital  branch  of  the  genito-crural  ner\-e,  descends  along  the  external  iliac  artery,  pierces 
the  transversahs  fascia,  and  passing  through  the  internal  abdominal  ring  descends  along  the  back 
part  of  the  spermatic  cord,  and  supphes  in  the  male  the  cremaster  muscle. 


462 


tents,  is  hardened  and  thickened  by  agglutination,  it  should  be  drawn  out,  tied 
off  in  sections  with  ISTo.  2  catgut,  the  abnormal  portions  removed,  and  the  stump 
returned  to  the  peritoneal  cavity.  In  tying  the  ligatures  a  third  knot  should 
be  used.  The  section  should  be  one  fourth  of  an  inch  beyond  the  ligature,  and 
each  stump  should  be  carefully  tested  for  bleeding  before  returning.  It  is  ad- 
visable at  this  stage  of  the  operation  to  have  the  patient  placed  in  the  modified 
Trendelenburg  posture,  so  that  gravity  may  carry  the  intestines  and  omentum 
toward  the  diaphragm  and  leave  the  inguinal  canal  free. 

In  dealing  with  the  sac  the  method  of  Maceioen  is  preferable  (although  many 
operators  of  large  experience  prefer  simple  ligation  of  the  sac  at  the  level  of  the 
abdominal  wall  with  No.  2  catgut).     If  the  sac  is  large  and  thick  it  should  be 

cut  away  to  within  one  inch  of  the 
internal  ring.  It  is  transfixed  at  the 
end  with  a  long  fourth-curved  Hage- 
dorn  needle  armed  with  a  strong  No.  2 
ten-day  catgut,  which  is  at  once  tied. 
.  The  needle  is  now  carried  through 
both  walls  of  the  sac  from  below  up- 
ward one  fourth  of  an  inch  from  the 
knot,  back  again  in  an  opposite  direc- 
tion one  fourth  inch  lower,  and  finally 
from  below  upward  the  same  distance 
beyond  (or  one  fourth  of  an  inch  from 
the  level  of  the  peritonffium  lining  the 
abdominal  wall  at  the  internal  ring). 


Fig.  4S4. — Showing  the  method  of  separating 
with  the  finger  tlie  sac  from  the  margins  of 
the  internal  ring  and  conjoined  tendon.  (Af- 
ter Mace  wen.) 


Fig.  485. — Showing  the  sac  folded  up  and  cover- 
ing the  abdominal  aspect  of  the  internal  ring. 
(After  Macewen.) 


the  point  directed  upward.  Pressing  the  back  of  the  needle  point  into  the  tip 
of  the  palmar  surface  of  the  index-finger,  it  is  carried  by  the  introduction  of  tliis 
finger  to  the  bottom  or  upper  limit  of  the  pocket,  and  thence  is  made  to  transfix 
the  muscles  and  skin  of  the  abdominal  wall,  coming  out  above  the  upper  angle 
of  the  skin  incision. 

The  operator  should  now  assure  himself  that  there  is  no  imprisonment  of 
omentum  or  intestine  in  the  sac  or  its  neck,  and  this  done,  traction  upon  the 
catgut  suture  folds  the  sac  upon  itself  when  it  is  drawn  tightly  into  the  pocket 
and  against  the  wall  of  the  abdomen  (Fig.  485).  It  is  held  firmly  in  this  posi- 
tion by  attaching  a  large-sized  forceps  to  the  end  of  the  suture  until  the  opera- 
tion is  completed,  when  at  the  level  of  the  skin  it  is  wound  in  flgure-of-8  fashion 
about  a  pencil  of  gauze  an  inch  long  and  half  an  inch  in  diameter.  Within  twelve 
to  twenty-four  hours  adhesions  occur  between  the  surfaces  folded  together  by  this 
method,  and  the  sac  is  entirely  obliterated.  Instead  of  a  funnel-shaped  depres- 
sion on  the  under  surface,  which  is  inevitable,  no  matter  how  high  up  the  neck 
of  the  sac  is  tied,  there  is  formed  by  Macewen's  method  a  boss  or  projection  where 
the  neck  of  the  sac  was  situated. 

The  next  step  in  the  operation  consists  in  stitching  the  arched  fibers  or  con- 


HERNIA  463 

joined  tendon  of  the  internal  oblique  and  transversalis  muscle  to  the  shelving  or 
scroll-like  edge  of  Poupart's  ligament  (Bassini's  plastic  operation).  Strong  kan- 
garoo tendon  should  be  used.  If  this  cannot  be  obtained,  Xo.  3  or  No.  i  chromic- 
acid  catgut  should  be  employed. 

These  sutures  are  inserted  with  a  half-curved  Hagedorn  needle.  The  sper- 
matic cord  is  held  out  of  the  way  and  slight  upward  traction  made  upon  it  by 
means  of  a  thin  strip  of  gauze  or  thread  passed  beneath  it.  The  first  suture  is 
inserted  into  the  internal  oblique  and  transversalis  muscle  about  one  quarter  of 
an  inch  from  the  arched  border,  and  should  be  very  near  the  upper  limit  of  the 
cord.  The  inguinal  nerve  should  be  carefullj^  excluded  from  the  grasp  of  the 
suture.  The  needle  is  carried  beneath  the  cord,  readjusted  in  the  needle  holder, 
and  the  point  carried  through  Poupart's  ligament  from  below  upward,  coming 
out  one  eighth  to  one  quarter  of  an  inch  from  its  free  border.  This  first  suture 
is  the  most  important.  An  artery  forceps  is  fastened  to  either  end,  and  holds 
it  in  position  until  ready  for  tying.  The  next  suture  should  be  about  one  quarter 
of  an  inch  farther  down,  and  should  be  inserted  on  a  plane  somewhat  farther  from 
the  edge  than  the  first,  also  avoiding  the  nerve.  It,  too,  is  carried  imderneath  the 
cord,  and  passes  through  Pouparfs  ligament  one  quarter  of  an  inch  below  the 
first  suture.  In  passing  the  point  of  the  needle  from  below  upward  through  Pou- 
part's ligament,  it  must  not  be  forgotten  that  the  iliac  vein  is  very  near,  and 
that  it  has  been  wounded  in  this  operation.  By  retracting  the  free  edge  of  the 
aponeurosis  of  the  external  oblique  and  bringing  the  ligament  in  clear  view  this 
accident  should  not  happen.  Two  more  ligatures  are  required,  and  a  fifth  may 
be  inserted  if  necessary. 

When  (as  occurs  in  large  old  hernis  where  a  truss  has  long  been  worn)  the 
tissues  are  atrophied  and  thin  from  pressure,  it  may  be  necessary  to  include  in 
the  last  one  or  two  sutures  a  part  of  the  outer  edge  of  the  rectas  abdominalis 
muscle.  In  tying  the  first  knot  of  the  first  suture  (nearest  the  cord),  it  should 
be  drawn  and  held  fast  for  a  few  moments  until  the  surgeon  is  convinced  that  too 
much  tension  is  not  being  exercised  upon  the  cord.  In  regulating  the  tension  of 
these  sutures  the  suture  forceps  is  very  useful.  The  author's  instrument  con- 
sists of  an  ordinary  dissecting  forceps  without  teeth  or  ridges,  perfectly  smooth, 
with  no  cutting  edge. 

When  the  first  loop  is  drawn  to  the  required  tension  the  forceps  grasps  and 
holds  it  until  the  second  knot  is  tied.  A  third  knot  should  be  tied  in  all  animal 
ligatures.  In  tying  this  row  of  sutures  very  little,  if  any,  tension  should  be  exer- 
cised in  approximating  the  arched  border  and  edges  of  the  transversalis  and  inter- 
nal oblique  and  rectus  muscles  to  Pouparfs  ligament,  for  the  reason  that  any 
tension  will  soon  cut  through  the  soft  muscular  fasciculi.  It  is  intended  simply 
to  hold  them  in  apposition  without  tension  until  connective-tissue  proliferation 
occurs  and  the  tissues  become  permanently  welded  in  this  new  position. 

The  wound  is  thoroughly  dried,  the  spermatic  cord  resting  upon  the  deep  row 
of  sutures  while  the  split  aponeurosis  of  the  external  oblique  is  reunited  by  a 
running  suture  of  kangaroo  tendon.  In  fat  subjects  a  subcutaneous  ten-day  catgut 
suture  should  be  used  to  approximate  the  edges  of  areolar  tissue  while  a  subcu- 
ticular silkworm-gut  suture  may  be  used  to  close  the  wound  in  the  skin.  The 
skin  should  be  thoroughly  cleansed  and  dried,  all  serum  or  moisture  expressed  from 
the  wound,  the  dressing  laid  on,  and  compression  continued  as  the  dressing  is 


The  catgut  ligature  attached  to  the  sac  and  drawn  through  the  skin  above 
the  upper  angle  of  the  incision  should  be  fastened  as  directed.  A  dry  sterile 
gauze  dressing  and  compress  held  in  place  by  a  snug  spica  completes  the  operation. 

A  certain  proportion  of  cases  of  hernia  in  males  are  complicated  with  vari- 
cocele. When  these  varicosities  are  large,  several  of  the  veins  should  be  removed, 
as  in  the  operation  for  the  cure  of  varicocele. 

By  this  procedure  the  cord  is  reduced  to  the  normal  size,  and  is  not  so  apt 
to  be  a  factor  in  reproducing  a  hernia  (Halsted).  The  patient  should  rest  quietly 
in  bed  for  at  least  two  weeks  after  the  operation,  and  the  figure-of-8  bandage  and 
compress  should  remain  snugly  adjusted  in  order  to  support  the  abdominal  wall. 


464  HERNIA 

The  upright  posture  should  not  be  permitted  until  the  end  of  the  third  week, 
and  all  movements  should  be  carefully  guarded  and  the  compress  and  bandage 
worn  for  several  weeks  longer.  When  the  hernia  is  large  and  of  long  standing,  the 
canal  greatly  dilated,  and  the  tissues  are  weak  and  thin,  the  period  of  rest  in 
bed  should  be  extended  to  four  or  five  weeks  and  extra  precautions  taken  to  insure 
the  best  possible  result. 

The  operation  for  the  cure  of  direct  inguinal  hernia  does  not  differ  materially 
from  that  just  given.  In  certain  cases  the  peritonEeum  in  front  of  the  hernial 
protrusion  is  not  sacculated,  the  tumor  having  a  sessile  appearance.  The  patient 
should  be  placed  in  the  full  Trendelenburg  posture,  the  peritonaeum  incised  as 
in  an  ordinary  laparotomy,  and  made  tense  by  overlapping  the  edges  with  the  run- 
ning catgut  suture.  The  plastic  work  is  the  same,  as  advised  by  Bassini.  When 
the  aponeuroses  are  relaxed  the  overlapping  suture  method  of  Championniere  should 
be  used. 

The  contents  of  the  sac  may  be  omentum  alone  or  small  intestine  and  mesen- 
tery, or  the  caecum  and  vermiform  appendix,  or  occasionally  the  transverse  colon. 
In  a  number  of  instances  the  author  has  removed  the  appendix  in  a  hernial  sac 
of  the  right  side,  treating  the  stump  as  advised  in  the  technic  of  appendectomy. 
He  has  also  removed  the  diseased  appendix  from  its  normal  location  through  the 
ordinary  hernial  incision. 

In  the  operation  for  the  cure  of  congenital  hernia,  the  technic  differs  for  the 
reason  that  the  spermatic  cord  is  in  the  hernial  sac   (Fig.  476). 

After  opening  the  sac  and  reducing  the  contents,  the  sac  is  freed  from  the 
cord  by  clipping  with  the  scissors  to  the  level  of  the  internal  ring.  The  divided 
edges  are  reunited  by  a  running  catgut  suture.  The  sac  'thus  made  is  treated  after 
Macewen's  method,  as  already  described. 

In  very  rare  instances  the  bladder  forms  a  part  of  the  contents  of  an  inguinal 
hernia.  Should  the  involvement  of  this  organ  be  suspected,  a  sound  introduced 
through  the  urethra  will  demonstrate  the  proximity  of  the  bladder  wall  to  the 
inguinal  canal. 

Treatment  of  Strangulated  Inguinal  Hernia. — With  the  first  symptom  of 
strangulation  the  patient  should  be  placed  in  the  semi-Trendelenburg  posture  while 
the  pubes,  scrotum,  and  integument  in  the  field  of  operation  is  being  shaved, 
scrubbed,  and  rendered  aseptic.  With  the  thighs  flexed  on  the  abdomen,  if  gentle 
manipulation  combined  with  gravitation  does  not  within  a  few  minutes  succeed 
in  the  reduction,  immediate  operation  is  imperative.  The  employment  of  force 
in  the  effort  at  taxis  is  not  justifiable.  Should  the  patient  be  capable  of  self- 
control,  the  analgesia  of  cocaine  infiltration  should  be  preferred  to  general  narcosis.. 
Should  it  become  necessary,  ether  narcosis  may  be  substituted. 

The  incision  shoiild  be  the  same  as  above  given,  cutting  directly  down  upon 
the  mass,  or  pinching  up  the  integument,  transfixing,  and  cutting  upward  and 
away  from  the  tumor.  As  soon  as  the  sac  is  thoroughly  exposed  and  freed  from 
the  overlying  tissues  down  to  the  external  ring,  it  should  be  carefully  opened, 
and  the  tip  of  the  index-finger  carried  down  to  the  constriction.  With  the  finger 
as  a  guide  and  as  a  shield  between  the  knife  and  the  intestine,  a  prolje-pointed 
bistoury  is  carried  along  the  palmar  surface  and  the  constriction  divided.  Or 
the  external  ring  may  Ije  incised  and  the  aponeurosis  split  as  in  the  operation  for 
the  radical  cure.  Irrigation  with  hot  salt  solution  should  be  done,  and  if  the 
released  bowel  takes  on  its  normal  color  it  shoidd  be  returned  to  the  peritoneal 
cavity. 

Should  the  condition  of  the  patient  justify  it,  the  operation  for  the  radical 
cure  should  at  once  be  carried  out  as  already  given.  If,  on  the  other  hand,  gan- 
grene has  taken  place  and  the  patient's  condition  is  such  that  no  operation  beyond 
the  relief  of  strangulation  is  permissible,  nothing  further  than  the  estal^lishment 
of  a  temporary  artificial  anus  should  be  attempted. 

If  adhesions  have  not  formed  and  there  is  danger  of  the  liberated  intestine 
dropping  into  the  peritoneal  cavity,  silk  sutures  should  be  inserted  to  hold  it  in 
place. 

Within  two  or  three  days,  or  as  soon  as  the  conditions  are  favorable,  resection 


HERNIA  465 

of  the  gangrenous  section  and  end-to-end  anastomosis  should  be  done,  as  described 
on  another  page. 

Inguinal  hernia  in  the  female  has  the  same  relation  to  the  epigastric  vessels 
as  in  the  male.  In  the  complete  form  the  contents  may  descend  into  the  labium. 
The  teehnic  is  simpler  for  the  reason  that  there  is  no  spermatic  cord.  Cysts  of 
the  canal  of  Nuck  not  infrequently  simulate  a  hernial  tumor,  or  the  ovary  blad- 
der and  occasionally  the  Fallopian  tube  may  be  found  in  the  sac. 

Herniotomy  ivith  Local  Anwsthesia. — Operations  for  the  relief  of  strangulated 
hernia,  and  for  the  radical  cure  of  a  fair  proportion  of  all  varieties  of  lierniEe,  can 
be  very  satisfaetoril}'  done  under  local  anaesthesia.  Solutions  of  cocaine  or  quinia 
and  urea  are  employed.  If  cocaine  is  used  the  endermie  infiltration  for  the  entire 
extent  of  the  proposed  incision  is  made  with  the  1-500  stock  solution,  while  for 
the  subcutaneous  infiltration  the  1-1000  solution  is  employed  (J.  A.  Bodine). 
A  one-per-cent  solution  of  the  hydrochloride  of  quinia  et  urea  (gr.  v  to  §J  of  a 
normal  salt  solution)  will  produce  a  very  satisfactory  analgesia,  and  without  any 
danger  from  absorption.  When  the  line  of  incision  has  been  anfesthetized  by  endo- 
cuticular  injection,  the  subcutaneous  infiltration  with  either  of  these  agents  should 
be  made  before  cutting  through  the  skin. 

The  teehnic  of  the  operation  is  practically  the  same  as  that  already  given. 
After  the  skin  and  subcutaneous  fat  is  divided  and  the  aponeurosis  of  the  external 
oblique  muscle  is  exposed,  this  should  be  split  for  about  two  inches  in  the  direc- 
tion of  its  fibers  just  over  the  known  situation  of  the  internal  ring.  By  careful 
retraction  of  the  edges  the  inguinal  branch  of  the  ilio-inguinal  nerve,  filaments 
of  which  emerge  at  the  external  ring,  will  be  seen.  It  should  be  cocainized  at 
once  at  the  highest  accessible  point  by  injecting  into  or  immediately  in  contact 
with  the  trunk,  several  minims  of  the  stock  solution.  The  painless  splitting  of 
the  aponeurosis  may  now  be  continued  until  it  opens  into  the  external  ring.  The 
outer  flap  is  carefully  dissected  up  with  the  blunt  scissors  until  the  shelving  process 
of  Poupart's  ligament  is  brought  clearly  into  view,  while  the  inner  flap  is  also 
lifted  for  about  an  inch. 

If  the  tissues  are  not  clouded  by  unnecessarily  rough  swabbing,  the  ilio-hypo- 
gastric  nerve  may  now  be  seen  where  it  pierces  the  inner  oblique  muscle  and  at 
once  cocainized.  Should  it  not  be  seen  and  pain  is  felt,  a  free  instillation  of  the 
weaker  solution  should  be  made  into  the  arched  fibers  of  the  internal  oblique  and 
transversalis  muscles. 

The  same  solution  may  be  freely  infiltrated  for  the  entire  extent  of  the  inci- 
sion into  the  coverings  of  the  hernial  protrusions,  and  especially  around  but  not 
into  the  spermatic  cord  where  it  comes  through  the  internal  ring.  This  infiltra- 
tion is  intended  to  anaesthetize  the  genital  branch  of  the  genito-crural  nerve.  The 
sac  is  now  carefully  separated  from  the  cord  with  scissors  and  forceps,  and  treated 
as  heretofore  directed  with  all  the  details  of  the  hernia  teehnic. 

Femoral  Hernia. — A  femoral  hernia  descends  between  Poupart's  ligament 
above,  the  upper  surface  of  the  horizontal  ramus  of  the  pubes  below,  a  sharp 
scythe-shaped  reflection  of  Poupart's  ligament  toward  the  median  line  of  the  body 
called  Gimbernat's  ligament,  and  the  femoral  vein  to  the  outer  side,  between  which 
and  the  hernial  sac  is  an  arched  reflection  of  the  deep  fascia  of  the  thigh  (Figs. 
479  and  480).  This  (the  femoral  ring),  of  comparatively  small  caliber,  is  chiefly 
composed  of  bone  and  unyielding  connective  tissue,  the  sharp  borders  of  which 
conduce  readily  to  strangulation. 

In  front  of  the  escaping  sac  there  is  a  second  reflection  of  the  fascia  of  the 
thigh,  which  covers  the  saphenous  opening  and  is  attached  above  to  the  deep  fascia 
which  covers  the  aponeurosis  of  the  external  oblique  muscle.  In  Fig.  480  it  has 
been  removed  to  show  the  hernial  sac.  It  is  this  reflection  of  the  deep  fascia 
which  arrests  the  downward  direction  of  a  femoral  hernia  and  turns  it  upward, 
more  sharply  in  contact  with  the  edge  of  Poupart's  and  Gimbernat's  ligaments. 

These  anatomical  facts  will  explain  the  extraordinary  danger  of  femoral  hernia 
and  make  it  imperative  that  the  surgeon,  with  tlie  first  appearance  of  the  tumor, 
advise  immediate  operation  for  the  radical  cure.  It  may  be  safely  said  that  no 
form  of  truss  is  safe  in  femoral  hernia,  and  none  should  be  prescribed  without 


466  HERNIA 

impressing  this  fact  upon  the  patient's  mind.  At  the  first  suggestion  of  strangu- 
lation there  is  no  other  alternative. 

Diagnosis. — The  protrusion  is  first  noticed  just  below  and  near  the  center  of 
Poupart's  ligament.  Its  appearance  may  have  been  preceded  either  by  distinct 
pain  or  an  uneasy  feeling,  as  of  "  something  giving  way."  In  the  further  escape 
of  the  hernia  it  is  deflected  upward  by  the  superficial  layer  of  the  deep  fascia  of 
the  thigh,  and  it  may  cross  in  front  of  Poupart's  ligament,  and  appear  as  a 
tumor  in  the  location  of  an  inguinal  protrusion. 

A  diagnosis  is  rendered  difficult  in  fleshy  individuals.  The  differentiation  is 
chiefly  between  enlarged  inguinal  glands,  abscess  (psoas),  and  inguinal  hernia. 
In  thin  subjects  the  line  of  Poupart's  ligament  can  be  readily  followed,  and  a 
protrusion  below  this  excludes  inguinal  hernia.  Should  an  impulse  be  given  to 
this  protrusion  in  the  act  of  coughing,  the  diagnosis  is  clear. 

Lyraphomata  of  the  groin  are  usually  hard,  cover  a  considerable  area,  and 
their  peculiar  shape  and  mobility  should  render  them  easy  of  recognition.  When 
infection  has  occurred,  they  are  painful  under  pressure,  which  does  not  hold  good 
in  a  hernia  not  strangulated. 

Syphilitic  adenitis  is  not  painful,  and  may  be  determined  as  a  sequence  of 
the  initial  lesion. 

Psoas  abscess  may  point  under  Poupart's  ligament  and  simulate  a  hernial  pro- 
trusion, but  with  this  collection  of  pus  there  is  almost  invariably  a  history  of 
tuberculous  osteitis  of  the  vertebra.  The  introduction  of  the  tip  of  index-finger 
through  the  external  abdominal  opening  into  the  inguinal  ring,  should  feel  the 
impulse  imparted  to  an  inguinal  hernia.  In  the  absence  of  this  sign,  a  second 
protrusion  slightly  below  this  location  to  which  an  impulse  is  imparted  would 
make  clear  the  recognition  of  a  femoral  hernia. 

Strangulated  Femoral  Hernia. — At  the  first  suggestion  of  strangulation  the 
patient  slaould  be  placed -on  the  back  in  the  modified  Trendelenburg  posture,  the 
thighs  fiexed  on  the  abdomen  and  gentle  pressure  exercised  in  an  effort  at  reduc- 
tion. If  within  ten  or  fifteen  minutes  this  cannot  be  accomplished  (and  under 
no  circumstances  shoidd  force  be  employed),  immediate  operation  is  imperative, 
and  may  be  done  with  perfect  satisfaction  with  local  anaesthesia. 

The  technic  of  infiltration  does  not  differ  from  that  for  inguinal  hernia.  The 
incision  is  the  same  as  given  for  the  radical  cure. 

As  soon  as  the  sac  is  reached  and  freed,  it  should  be  carefully  punctured, 
and  as  the  first  few  drops  of  fluid  exude,  a  grooved  director  should  be  inserted 
and  the  opening  made  large  enough  to  admit  the  index-finger.  The  sac  and 
contents  should  be  well  flushed  with  hot  normal  salt  solution  (110°  to  115°  F.). 
The  tip  of  the  finger  should  be  carried  to  the  constricting  edge  of  Gimbernat's 
ligament,  and  with  the  palmar  surface  as  a  guide,  the  finger  being  between  the 
contents  of  the  sac  and  the  knife,  a  probe-pointed  bistoury  is  carried  through  the 
constriction  just  at  the  attachment  of  Gimbernat's  ligament  to  the  pubic  bone, 
and  this  divided  by  turning  the  edge  of  the  knife  toward  the  median  line  and  cut- 
ting close  to  the  surface  of  the  bone,  a  distance  of  about  one  quarter  of  an  inch. 
If  the  circulation  in  the  hernial  contents  is  not  satisfactory  within  from  two  to 
five  minutes,  the  constriction  should  be  still  further  divided  in  the  same  direction, 
and  the  ring  stretched  by  the  finger.  If  the  loop  of  intestines  still  remains  black 
or  dark  brown,  without  any  tendency  to  clear  up  within  ten  minutes  after  the 
strangulation  is  thoroughly  relieved,  one  of  two  alternatives  remains : 

If  the  patient's  condition  is  such  that  a  prolonged  operation  is  contra-indicated, 
a  temporary  artificial  anus  should  be  made  by  drawing  the  upper  segment  of  the 
loop  one  half  inch  farther  through  the  constriction  and  stitching  it  with  linen 
or  silk  sutures  to  the  edge  of  Poupart's  ligament,  or  to  the  skin,  to  prevent 
infection  of  the  j)eritoneal  cavity.  The  loop  should  then  be  incised.  If  there 
is  not  a  free  escape  of  intestinal  contents  through  this  opening,  a  forceps 
should  be  introduced  into  the  lumen  of  the  upper  segment,  which  should  be 
stretched. 

The  operation  of  excising  the  gangrenous  portion  of  the  loop  and  reuniting 
the  ends  by  direct  anastomosis  may  be  done  at  a  later  period,  preferably  at  the 


HERNIA  467 

earliest  possible  moment,  since  the  lower  unused  end  soon  becomes  much  smaller 
in  diameter. 

In  performing  this  later  stage  excision  for  imprisoned  hernia  with  fecal  fistula, 
in  order  not  too  greatly  to  enlarge  the  femoral  opening  in  the  effort  to  disengage 
and  bring  out  both  ends  of  the  open  gut,  a  near-by  incision  through  the  rectus 
or  linea  alba  may  be  utilized,  and  the  imprisoned  segments  released  and  brought 
out  here  for  suture.  The  femoral  canal  should  always  be  closed  by  that  method 
for  the  radical  cure  which  may  seem  best  adapted  to  the  case  in  hand. 

If,  on  the  other  hand,  the  conditions  are  favorable  for  immediate  exsection  and 
reunion,  after  careful  disinfection  of  the  contents  and  sac  by  free  irrigation  with 
hot  salt  solution,  followed  by  1-1000  mercuric  chloride  and  again  by  the  saline, 
both  ends  of  the  loop  of  intestine  should  be  drawn  well  out  from  the  canal  and 
anastomosis  performed  as  given  on  another  page. 

Should  it  be  clear  to  the  mind  of  the  surgeon  that  a  more  hurried  anasto- 
mosis should  be  made  than  that  by  suture,  the  Murphy  button  may  be  substituted. 

In  general  these  various  operations  can  be  successfully  and  satisfactorily  per- 
formed with  local  anesthesia  unless  the  subject  be  extremely  nervous  or  hys- 
terical and  loses  self-control.  Should  complete  narcosis  become  imperative  the 
preliminary  use  of  these  agents  is  no  bar  to  nitrous  oxide  and  ether  (or  chloro- 
form). When  the  anastomosis  is  complete  and  the  intestine  has  been  returned 
to  the  peritoneal  cavity,  the  operation  for  the  radical  cure  should  be  at  once 
carried  out. 

The  operation  for  the  radical  cure  of  femoral  hernia  has  given  results  as 
encouraging  as  that  for  the  inguinal  variety. 

An  incision  about  four  inches  long  is  made  parallel  with  the  lower  edge  of 
Poupart's  ligament,  its  center  being  over  the  femoral  canal  or  neck  of  the  sac. 
The  inner  end  of  this  incision  is  over  the  sharp  spine  of  the  pubes,  which  may 
readily  be  felt.  Carefully  dissecting  down  upon  the  sac,  this  should  be  isolated 
well  within  the  canal,  opened,  and  its  intestinal  contents  returned  to  the  peritoneal 
cavity,  any  omentum  tied  oif  with  strong  catgut  cut  away,  and  the  stump  returned. 
The  patient  should  now  be  placed  in  the  Trendelenburg  posture.  The  sac  should 
be  transfixed  about  three  quarters  of  an  inch  in  front  of  Gimbernat's  ligament 
with  a  Hagedorn  needle  armed  with  a  strong  No.  2  ten-day  chromic-acid  catgut 
strand,  the  end  of  which  is  tied  around  the  sac  at  the  point  of  transfixion.  Mak- 
ing tension  on  this  ligature,  the  index-finger  should  be  carried  along  the  upper 
surface  of  the  neck  of  the  sac  underneath  Poupart's  ligament,  separating  the  peri- 
toneum lining  the  al3dominal  wall  from  the  free  border  of  the  ligament  and 
aponeurosis,  making  a  pocket  in  which  the  neck  of  the  sac  is  to  be  inverted  in 
the  same  manner  as  the  method  of  Macewen  in  the  inguinal  hernia  operation. 

The  back  of  the  point  of  the  long  crescent-curved  Hagedorn  needle  is  now 
pressed  well  into  the  palmar  surface  of  the  index-finger,  the  point  directed  slightly 
toward  the  median  line  in  order  to  avoid  even  the  remote  possibility  of  wounding 
the  vein,  and  when  the  end  of  the  finger  is  reintroduced  through  the  femoral  canal 
the  needle  is  brought  directly  up  through  the  abdominal  wall,  piercing  the  integu- 
ment about  one  inch  above  Poupart's  ligament,  care  being  taken  in  male  subjects 
to  avoid  the  spermatic  cord.  Tension  on  this  ligature,  aided  by  direct  pressure, 
inverts  the  sac  and  holds  it  firmly  folded  in  the  new  position,  where  it  is  retained 
by  twisting  the  ligature  around  a  pencil  of  gauze  at  the  point  where  it  emerges 
through  the  integument. 

The  next  step  in  the  operation  is  to  stitch  the  lower  edge  of  Poupart's  liga- 
ment to  the  periosteum  and  fascia  along  the  origin  of  the  pectineus  muscle  from 
the  horizontal  ramus  of  the  pubes  (Fig.  486).  For  this  purpose  kangaroo  tendon 
should  be  employed,  and  considerable  care  is  necessary  in  passing  the  outermost 
suture,  which  is  practically  in  contact  with  the  sheath  of  the  femoral  vein.  This 
vessel  should  be  pressed  outward  by  the  finger  or  a  dull  instrument  while  the 
outermost  suture  is  being  inserted.  It  will  be  found  advantageous  to  loosen  the 
periosteum  with  the  fibers  of  insertion  of  the  pectineus  from  the  pubes  by  means 
of  a  small  sharp  elevator.  Since  the  obturator  artery  in  women  rises  from  the 
deep   epigastric   in  nearly   fifty  per   cent   of  cases,   and   in   males   in   twenty-five 


468  HERNIA 

per  cent,  a  careful  regard  should  be  had  for  this  vessel  and  its  accompanying 
vein.  The  deep  fascia  which  has  been  divided  in  the  earlier  part  of  the  dissection 
is  now  also  stitched  to  Poiipart's  ligament  by  chromic-acid  catgut,  and  the  wound 
closed  by  an  endocuticular  silkworm-gut  suture.  A  loose  gauze  dressing  and  the 
.iigure-of-8  spiea  compress  should  be  applied  and  worn  for  three 'weeks,  the  pa- 
tient resting  in  the  dorsal  decubitus  for  at  least  a  fortnight.  It  is  not  wise  to 
assume  the  upright  posture  under  three  tveeks,  and  this  only  when  firm  compres- 
sion is  being  made,  which  should  be  worn  for  three  or  four  weeks  longer. 

By  this  technic  femoral  herniiB  are  radically  cured  in  about  the  same  pro- 
portion of  cases  as  in  the  Bassini-Macewen-Halsted  procedure  for  inguinal  rupture. 


Fig.  486. — Radical  cure  of  femoral  hernia.      Stitches  to  close  lower  opening  of  femoral  canal  inserted, 
but  not  tied.      (Fowler's  "Surgery.") 

Prof.  Joseph  A.  Blake  has  originated  a  method  which  is  especially  directed  to 
the  more  perfect  closure  of  the  upper  opening  of  the  femoral  canal.  In  hernise 
of  long  standing,  or  where  the  canal  has  been  more  than  ordinarily  dilated,  it 
may  be  preferred. 

The  chief  feature  of  this  technic  is  the  introduction  of  a  mattress  suture 
parallel  with  Poupart's  ligament  in  such  manner  that  when  tied  it  acts  like  a 
purse  string  around  the  internal  orifice  of  the  femoral  canal. 

After  ligature  of  the  sac  and  carrying  it  into  the  abdominal  cavity,  with  the 
patient  in  a  modified  Trendelenlnirg  posture,  a  needle  armed  with  kangaroo  ten- 
don is  "  introduced  through  the  aponeurosis  of  the  external  oblique  muscle  from 
one  half  to  five  eighths  of  an  inch  above  its  lower  reflected  margin  on  the  mesial 
side  of  the  canal  directly  through  the  anterior  abdominal  wall,  and  is  made  to  pick 
up  Cooper's  ligament.^  The  needle  is  then  brought  out  of  the  lower  opening  of 
the  femoral  canal.  Then,  the  femoral  vein  being  protected  and  pushed  aside  by 
the  finger,  the  needle  is  passed  into  the  canal  and  picks  up  Cooper's  ligament  again 
at  the  lateral  side  of  the  canal,  and  is  passed  from  there  directly  forward  through 
the  anterior  abdominal  wall,  emerging  at  a  level  corresponding  to  the  point  of 

'  Cooper's  ligament  is  a  fold  of  the  fascia  transversalis  attached  to  the  ileo-pectineal  eminence 
and  spine  of  the  pubes.  Gimbernat's  ligament  is  the  triangular  expanse  of  the  aponeurosis  of 
the  external  oblique  muscle  anteriorly  joined  to  Poupart's  ligament  and  extending  to  the  ileo- 
pectineal  line. 


HERNIA 


469 


introduction.  Tliis  forms  a  mattress  stitch,  which,  when  tied  closely,  approximates 
the  deep  surface  of  Poupart's  ligament  to  the  dorsal  margin  of  the  femoral  ring 
and  completely  closes  the  mouth 
of  the  femoral  canal.  The  lower 
margin  of  the  canal  can  then  be 
stitched  to  the  fascia  of  the  pec- 
tineus  muscle  with  a  few  inter- 
rupted sutures,  thus  closing  the 
entire  canal  (Fig.  486). 

"  The  mattress  stitch  passes 
through  the  outer  pillar  of  the  ex- 
ternal inguinal  ring,  and  with  a 
little  care  the  spermatic  cord  is 
easily  avoided  in  the  male." 

Of  the  more  recent  procedures 
for  the  radical  cure  of  femoral 
hernia,  one  which  combines  some- 
thing of  the  method  of  Euggi  as 
applied  to  femoral  hernia  and  Bas- 
sini's  plastic  inguinal-  herniotom}'', 
is  that  devised  and  successfully 
demonstrated  by  Dr.  A.  V.  Mosch- 
cowitz : 

■  "  The  incision  through  the  skin, 
about  tivo  and  a  half  inches  long, 
is  parallel  with  and  about  one  inch 
above  Poupart's  ligament.  A  short 
vertical  incision  is  added  to  the 


Fig.  4S7. — Showing  tlie  ordinary  cutaneous  incision;  dot- 
ted line  indicates  the  occasionally  necessary  supple- 
mentary incision.     (Moschcowitz.) 


ta>  C<iAydj> 


Fig.  488. — Shows  the  parts  after  division  and  retraction  of  the 
aponeurosis  of  the  external  oblique.      (Moschcowitz.) 


lower  and  inner  end  (Fig. 
487).  The  aponeurosis  of  the 
external  oblique  is  exposed  and 
split  in  the  direction  of  its 
fibers,  as  in  Bassini's  opera- 
tion. Eetraction  of  the  lower 
flap  exposes  the  shelving  edge 
of  Poupart's  ligament  which 
forms  a  convenient  guide  to 
the  neck  of  the  femoral  sac. 
Eetraction  of  the  upper  flap  ex- 
poses the  conjoined  tendon  and 
the  arched  fibers  of  the  inter- 
nal oblique  and  transversalis 
muscles.  These  two  muscles, 
as  well  as  the  exposed  spermatic 
cord  or  rovind  ligament  are 
retracted  upward  by  the  blunt 
hook,  exposing  the  transversa- 
lis fascia.  This  is  also  incised 
and  retracted,  exposing  the 
neck  of  the  sac   (Fig.  488). 


470 


HERNIA 


"  The  sac,  jnst  before  it  dips  beneath  Poupart's  ligament,  is  now  incised,  and  its 
contents  are  reduced  in  the  usual  manner. 

"  A  dressing  forceps  is  introduced  through  the  internal  femoral  ring  to  the 
fundus  of  the  sac,  which  it  grasps,  and  if  no  adhesions  are  jjresent  the  sac  can 
be   entirely   inverted   and   pulled   through   the   ring,    so   that   the 
hernia  is  converted  from  a  femoral  into  a  direct  inguinal  hernia 
(Fig.  489). 

"  If  adhesions  have  occurred,  the  sac  should  be  dissected  out, 
or  if  this  is  difficult  cut  off  near  the  internal  femoral  ring.  The 
neck  of  the  sac  is  now  obliterated  flush  with  the  peritonseum 
either  by  transfixion  and  ligature  or  by  suture. 

"  In  closing  the  internal  fem- 
oral ring,  in  order  to  expose  it 
properly,  the  peritonaeum  should 
be   pushed  bluntly   upward   with 
a  broad  flat  retractor.     The  fol- 
lowing anatomical  structures  are 
now    in    sight :    Anteriorly    Pou- 
■^^^^^^£^^2^  part's    ligament,    externally    the 
S.f,.i^uyru>ytU-       external  iliac  vein  and  the  deep 
^2z:dy-.  epigastric  vessels,  internally  Gim- 

bernat's  ligament,  and  posteri- 
orly, but  on  a  slightly  higher 
level.  Cooper's  ligament  and  the 
pectineus  muscle  and  fascia, 
while  above  is  the  retracted 
peritoneum,  the  transversalis 
fascia,  internal  oblique  (and 
transversalis  muscles),  and  the 
aponeurosis   of   the   external   ob- 


. .  r-^  o?7~  a-t^ 


Fig.  489. — Shows  the  hernia  after  it  has  been 
converted  into  a  direct  inguinal  hernia. 
(Moschcowitz.) 

lique.  The  internal  femoral  ring 
is  thus  perfectly  exposed,  and  with 
the  greatest  ease  and  safety  it 
may  be  closed.  With  a  strong, 
small,  full-curved  needle,  armed 
with  strong  chromicized  catgut  (or 
kangaroo  tendon),  sutures  are  passed 
between  Cooper's  ligament  and  the 
periosteum  of  the  pubic  bone  on  the 
one  hand,  and  Poup)art's  ligament 
on  the  other,  over  the  site  of_  the 
femoral  ring  (Fig.  490).  When 
these  sutures  are  tied  it  will  be 
seen  that  Poupart's  ligament  has 
been  approximated  to  the  pubic  bone, 
thereby  completely  obliterating  the 
internal  femoral  ring.  In  a  major- 
ity of  instances  two  or  three  sutures 
will  suffice  to  entirely  close  the  ring. 
The  most  external  suture  goes  as 
near  as  possible  to  the  external  iliac 

rein  without  constricting  it,  while  the  most  internal  suture  includes  also  Gimber- 
nat's  ligament  (Fig.  491). 

"  The  filial  closure  of  the  wound  is  made  by  bringing  the  spermatic  cord  or  round 


Fig.  490. — Shows  the  parts  after  the  neck  of  the  sac  had 
been  ligated  and  the  peritonaeum  retracted.  All  the 
deep  structures  are  exposed  and  three  sutures  are 
passed  to  close  the  internal  femoral  ring.  (Mosch- 
cowitz. ) 


HERNIA 


471 


ligament  to  the  normal  position  and  inserting  chromicized  gut  (or  kangaroo  ten- 
don) sutures  to  the  number  of  four  or  five,  including  the  internal  oblique  and 
trausversalis  on  the  one  hand,  and 
on  the  other  Poupart's  ligament 
just  anteriorly  to  the  first  series 
of  sutures.  Care  must  be  taken 
to  leave  just  sufficient  room  at  the 
inferior  angle  for  the  emergence 
of  the  round  ligament  or  spermatic 
cord  (Fig.  493).  The  external 
oblique  is  closed  with  a  running 
kangaroo  tendon  suture  and  the 
skin  as  already  advised."  ^ 

With  the  proper  selection  of 
cases  and  the  application  of  the 
teehnic  above  given,  which  may 
be  best  suited  to  the  conditions 
present,  the  percentage  of  failures 
should  be  exceedingly  small. 

Umhilical  hernia  may  be  con- 
genital or  acquired.  The  former 
is  due  to  the  failure  of  union  in 


Fig.  491. — The  deep  sutures  closing  the  internal  femora* 
ring  have  been  tied  ;  and  four  sutures  have  been  passed 
to  prevent  the  occurrence  of  an  inguinal  hernia. 
(Moschcowitz.) 


CcHrfuA^u  g^c*?'. 


/       LU  'T,-\ 


the  development  of  the  tis- 
sues, which  compose  the  an- 
terior wall  of  the  abdomen 
at  the  navel.  Its  only  cover- 
ing is  the  thin  amniotic  layer 
of  the  cord. 

The  acquired  form  rarely 
occurs  before  puberty,  and  is 
most     frequent     in     women. 
Occasionally    the    protrusion 
escapes    at   the    side    of,    but    not    im- 
mediately  through,  the   umbilical   cica- 
trix. 

The  sac  may  contain  only  omentum, 
usually  the  large  intestine,  and  at  times 
coils  of  the  smaller  gut. 

The  diagnosis  of  congenital  hernia 
at  the  umbilicus  is  not  difficult.  In  the 
acquired  form  the  gradual  development 
of  the  tumor  and  the  impulse  imparted 
to  it  in  the  act  of  coughing  will  point 
very  directly  to  hernia.  Should  the  tu- 
mor disappear  with  the  recumbent  pos- 
ture, its  character  is  evident. 
The  treatment  of  the  congenital  variety  (omphalosis)  consists  in  most  careful 
asepsis,  with  protection  of  the  thin  covering  from  infection  and  rupture  by  a 
sterile  dressing,  around  which  is  placed  a  soft  ring  of  gauze,  and  over  all  a  second 
sterile  dressing,  held  in  place  by  adhesive  strips.  A  skin  and  muscle-plastic  oper- 
ation is  indicated  to  cover  the  tumor. 

'  Dr.  A.  V.  Moschcowitz,  "New  York  State  Journal,"  October,  1907. 


Fig.  492. — Condition  after  the  approxima- 
tion of  the  internal  oblique  and  transver- 
salis  to  Poupart's  ligament.  To  be  fol- 
lowed by  suturing  the  cut  edges  of  the 
aponeurosis  of  the  external  oblique  and 
of  the  skin.      (Moschcowitz.) 


472 


HERNIA 


In  the  acquired  form,  if  reducible,  a  compress  or  pad  fitted  so  that  pressure  is 
made  in  the  hernial  opening,  will  afford  temporary  relief.  The  pad  and  belt  should 
be  applied  and  tightened  while  the  patient  is  lying  down  with  the  thighs  flexed 
and  recti  muscles  relaxed. 

A  reducible  umbilical  hernia  is  a  constant  menace  to  the  safety  of  the  patient, 
and  when  irreducible  it  becomes  a  graver  danger  and  makes  an  operation  for  the 
radical  cure  imperative.  The  rational  procedure  requires  the  reduction  of  the 
mass,  the  ligation  and  removal  of  imprisoned  and  adherent  omentum,  closure  of 
the  peritoneal  neck  of  the  sac  by  suture,  and,  most  important,  overlajjping  of  the 
connective  tissues  (aponeuroses  and  sheaths)  forming  the  abdominal  wall  in  the 
region  of  the  navel. 

Operation  of  W.  J.  Mayo. — Two  transverse  elliptical  incisions  are  made,  cleanly 
exposing  the  neck  of  the  hernial  sac  and  the  aponeurotic  structures  for  several 
inches  above  and  below  it  (Fig.  493).  The  sac  is  opened,  the  intestinal  contents 
returned,  the  omental  contents  ligated  in  sections  with  a  strong  catgut  on  a  level 
with  the  abdominal  orifice,  and  the  stumps  returned  to  the  peritoneal  cavity.    The 


-Mayo's  operation  showing  tlie  transverse  elliptical  incisions  and  exposure  of  the 
neck  of  the  sac.     (W.  J.  Mayo.) 


sac,  with  all  of  the  adherent  omentum,  including  the  shin,  is  cut  away  without 
further  manipulation.  A  stout  curved  needle,  with  strong  celluloiden  linen  is 
passed  from  without  in  through  the  aponeurotic  structures  and  peritoneum  from 
two  to  three  inches  above  the  margin  of  the  opening.  To  guard  the  needle  as  it 
enters  the  peritoneal  cavity,  the  bowl  of  a  large  tablespoon  (Monks)  is  used,  the 
underlying  viscera  being  displaced  by  the  convex  surface  of  the  spoon.  The  needle 
and  thread  is  drawn  down  and  out  of  the  hernial  opening.  A  firm  mattress  stitch 
is  now  caught  in  the  upper  edge  of  the  lower  flap  alwut  one  quarter  of  an  inch 
from  the  margin ;  the  needle  is  then  carried  back  through  the  hernial  opening  into 
the  peritoneal  cavity,  and  made  to  emerge  one  third  of  an  inch  lateral  to  the  point 
of  original  entrance.  On  each  side  of  this  is  introduced  a  similar  mattress  suture 
of  strong  chromicized  catgut  (or  preferably  kangaroo  tendon)  (Fig.  494).  These 
three  sutures  are  drawn  tight,  pulling  the  entire  thickness  of  the  aponeurotic  and 
peritoneal  structures  behind  the  upper  flap.  The  margin  of  the  upper  flap  is 
retracted  to  expose  the  suture  line,  and  if  any  gap  exists  it  is  closed  with  cat- 
gut or  kangaroo  sutures.  The  edge  of  the  upper  flap  is  sutured  to  the  sur- 
face of  the  aponeurosis  below  (preferably  continuous  kangaroo  tendon  sutures) 
(Fig.  495). 

When  the  fat  is  thick,  which  is  almost  always  the  case  in  these  subjects,  it 
should  be  approximated  by  subcutaneous  chromic-acid  gut.    The  superficial  wound 


HERNIA  473 

is  closed  by  interrupted  silWorm  gut  or  a  running  subcuticular  suture  of  the 
same  material.  The  patient  should  remain  in  bed  without  exercising  unnecessary- 
strain  upon  the  abdominal  muscles  for  at  least  twenty-one  days,  and  longer  if 
the  opening  was  large  and  the  tissues  weak.  The  position  in  bed  on  the  back, 
propped  up  with  the  shoulders  well  elevated,  aids  in  preventing  muscular  strain. 


Fig.  494. — ^Tbree  mattress  sutures  introduced.     (Mayo.) 

When  strangulation  occurs,  immediate  operation  should  be  done.  If,  on  ac- 
count of  ingesta  in  the  stomach,  general  narcosis  cannot  be  safely  employed,  local 
infiltration  should  be  substituted.  In  expert  hands,  and  with  the  patient  under 
complete  self-control,  the  use  of  this  anaesthesia  is  very  satisfactory. 

Diaphragmatic  hernia  is  fortunately  of  rare  occurrence.  ••  The  symptoms  are 
those  of  acute  pain,  shock  due  to  obstruction  of  the  intestinal  tract  without  the 
objective  symptoms  of  hernia.  A  portion  of  the  stomach  is  occasionally  impris- 
oned in  an  opening  of  the  diaphragm.  In  cases  of  grave  doubt  an  exploratory 
iacision  is  advisable.  In  relieving  the  constriction  the  probe-pointed  bistoury 
should  be  used  and  the  least  possible  incision  made.     Should  the  opening  be 


Fig.  495. — Mattress  sutures  tied  above,  and  upper  edge  of  incision  stitched  to  surface  of 
aponeurosis  below.     (Mayo.) 

readily  accessible  it  may  be  closed  by  sutures  of  chromic-acid  catgut.     The  Meyer 
costoplastic  operation  may  be  utilized. 

The  recognition  of  gluteal  hernia  is  difficult.  If  with  the  symptoms  of  ob- 
struction there  is  pain  in  the  region  of  the  sciatic  notch,  and  this  is  conveyed 
along  the  distribution  of  the  gluteal  or  sciatic  nerve,  the  presence  of  hernia  may 
be  suspected.  Occasionally  the  tumor  may  be  felt.  The  notch  may  be  located  by 
placing  the  patient  in.  the  recumbent  posture,  when  a  line  drawn  from  the  pos- 


474  HERNIA 

terior-superior  spine  of  the  ilium  to  the  upper  surface  of  the  great  trochanter 
will  cross  directly  over  the  foramen. 

The  incision  should  be  free,  and  the  fibers  of  the  gluteal  muscles  separated  with 
the  finger,  as  considerable  care  is  necessary  to  avoid  wounding  the  artery,  which 
maizes  its  exit  here. 

Obturator  hernia  Taay  be  present  without  any  appreciable  tumor.  It  may  be 
recognized  by  digital  exj^loration  through  the  rectum  or  vagina.  Pressure  upon 
the  obturator  nerve  may  produce  pain  in  the  hip-  or  knee-joint.  An  incision 
through  the  linea  alba  above  the  pelvis  will  enable  the  operator  to  recognize  with 
the  index-finger  whether  or  not  this  form  of  hernia  exists.  If  necessary,  a  counter- 
incision  may  be  made  irftmediately  over  the  foramen  and  the  constriction  divided 
from  below.  The  fibers  of  the  pectineus  muscle  will  lie  directly  in  front  of  the 
hernial  tumor. 

Lumbar,  vaginal,  and  pudendal  hernise  do  not  demand  special  consideration. 
The  diagnosis  will  depend  upon  the  appearance  of  the  tumor  with  the  symptoms 
of  strangulation  when  the  constriction  is  sufficient. 

Hernia  in  children  was  formerly  treated  by  the  careful  adjustment  of  a  truss, 
but  the  low  death-rate  and  the  large  proportion  of  cures  by  the  Bassini  operation 
has  led  to  the  abandonment  of  this  method  of  treatment  in  favor  of  operation. 
The  technic  differs  in  no  essential  features  from  that  already  advised  for  adults. 
In  young  male  children  the  spermatic  cord  should  be  handled  with  great  care  for 
fear  of  injury  to  the  vas  deferens  and  blood  vessels. 

For  the  radical  cure  of  ventral  hernia  the  incision  should  be  made  to  conform 
in  general  to  the  shape  of  the  opening  through  the  abdominal  wall.  The  con- 
tents are  usually  closely  adherent  to  the  deep  fascia  or  cicatrix,  and  this  to  the 
integument,  rendering  great  care  necessary  in  order  to  avoid  wounding  the  intes- 
tine. In  general,  it  is  advisable  to  enter  the  peritoneal  cavity  at  one  point  close 
to  the  line  of  incision,  and  through  this  to  introduce  the  index- finger  in  order  to 
determine  the  extent  and  limit  of  the  adhesions.  These  should  be  carefully  sepa- 
rated and  the  contents  of  the  sac  freed,  any  imprisoned  omentum  tied  off  with 
ordinary  catgut,  and  the  stumps  returned  with  the  intestinal  contents  to  the  peri- 
toneal cavit}'.  The  peritonaeum  lining  the  anterior  wall  of  the  abdomen  which 
forms  the  hernial  sac  should  be  smoothly  trimmed  around  the  margins  of  the 
aperture,  and  separated  for  about  one  half  inch  from  the  under  surface  of  the 
abdominal  wall  and  closed  by  a  separate  running  suture  of  chromicized  catgut. 
The  silk  loop  retractors  described  in  the  operation  for  appendectomy  may  be  used 
here  with  great  satisfaction.  The  aponeurotic  or  muscular  layers  should  be  closed 
with  kangaroo  tendon  separately  by  the  overlapping  mattress  sutures  of  Noble. 
If,  on  account  of  great  tension,  the  lateral  overlapping  method  cannot  be  em- 
ployed, the  up-and-down  overlap  method,  as  advised  for  umbilical  hernia  by  W.  J. 
Mayo,  may  be  substituted. 

In  hernise  of  long  standing,  where  a  large  aperture  exists,  and  where  the  mus- 
cular aponeuroses  have  become  atrophied  and  weakened  by  pressure  either  from 
a  supporting  apparatus  or  the  weight  of  the  tumor  itself,  it  will  be  found  impos- 
sible successfully  to  utilize  the  tissues  in  any  plastic  work  for  the  radical  cure. 
This  condition  may  occur  at  the  umbilicus,  the  inguinal  canal,  or  elsewhere.  Un- 
der such  conditions  the  silver  wire  wicker  work  or  Bartlett's  filigree  may  be  suc- 
cessfully applied. 

The  technic  is  as  follows :  ^  An  incision  is  made  over  the  hernial  protrusion, 
the  sac  is  opened,  and  its  contents  reduced.  The  excess  of  the  sac  is  cut  away 
and  the  edges  sutured  as  would  be  done  in  closing  the  healthy  peritonaeum.  The 
peritonteum  is  now  separated  from  the  inner  surface  of  the  abdominal  wall  to  a 
depth  of  about  half  an  inch  throughout  the  entire  circumference  of  the  hernial 
opening. 

On  the  bed  thus  formed  by  the  peritonaeum  a  filigree  (Fig.  496)  slightly  longer 
and  wider  than  the  opening  is  placed  in  position,  being  overlapped  by  all  the 
tissues  anterior  to  the  peritonffium.     It  is  held  in  position  by  catgut  sutures  at  its 

'  Willard  Bartlett,  M.D.,  "Transactions  of  the  American  Medical  Association,"  1906. 


HERNIA 


475 


extreniities.  If  the  defect  is  large  and  the  tissues  cannot  be  united  over  the  filigree^ 
they  should  be  approximated  as  near  as  possible  with  kangaroo  tendon  sutures. 
All  that  is  necessary  is  that  the  edges  of  the  network  should  be  covered  for  a  short 
distance.     Over  this  the  fat  and  skin  are  closed  in  the  ordinary  manner. 


Fig.  496. — Bartlett's  silver  wire  filigree.     (Kny-Scherer.) 

The  patient  should  be  kept  in  bed  for  at  least  three  weeks  (in  severe  cases 
longer),  and  a  binder  is  worn  for  several  weeks  after  convalescence.^ 

'  Dr.  Bartlett  rejwrts  a  number  of  cases  successfully  treated  by  this  method,  and  Dr.  Joseph 
Wiener,  Jr.,  in  the  "Annals  of  Surgery,"  April,  1906,  reports  an  additional  group  of  successful 
cases  and  highly  commends  the  practical  success  of  the  method.  The  filigree  should  be  made 
of  thin  pliable  wire,  as  shown  in  the  illustration,  not  heavier  than  gauge  No.  30. 


CHAPTER    XXVI 

RECTUM    AND    AlfUS ATRESIA CUTANEOUS    LESIONS PARASITES FOREIGN    BODIES 

ABSCESS FISTULA — GANT's   OPERATION ULCERS — STRICTURE NEOPLASMS 

RESECTION — PROLAPSUS NEURALGIA IliEMORRHOIDS 


RECTUM  AND  ANUS 

Aisencc  of  the  anus  is  one  of  the  most  frequent  congenital  lesions  of  the  ali- 
mentary outlet.  The  rectum  may  be  partially  developed,  and  terminate  within 
the  pelvis  in  a  blind  pouch  at  a  point  more  or  less  removed  from  the  normal 
opening  (Fig.  497)  ;  there  may  be  a  partial  development  of  the  anus  (Fig.  498)  ; 
the  rectum  may  be  entirely  absent  (Fig.  -499) ;  or  it  may  be  present  in  the  pelvis, 
opening  abnormally  into  the  bladder,  vagina,  uterus,  or  urethra   (Figs.   500  and, 


Fig.  497. — Atresia  of  the  anus. 
Esmarch.) 


(After 


Fig.  49S. — Atresia  of  the  rectum,  witli  a  rudi- 
mentary anus.      (After  l^sinarcli.) 


501).  In  the  simpler  forms  of  atresia  ani  only  a  thin  membrane  is  stretched 
across  the  otherwise  normal  opening.  The  more  complicated  varieties  are  those 
in  which  a  greater  distance  intervenes  between  the  end  of  the  defective  intestine 
and  the  perinseum. 

Diagnosis. — Absence  of  the  anus  is  easily  established  by  inspection.  The  more 
important  and  difficult  point  is  to  determine  the  distance  from  the  perinseum  to  the 
end  of  the  pouch.  When  the  intervening  tissue  is  thin,  the  accumulation  of  matter 
within  the  tube  may  cause  a  protrusion  in  the  perinajum,  which  is  exaggerated 
when  the  infant  cries.  If  the  finger  be  pressed  into  the  perinaaum,  an  impulse 
somewhat  comparable  to  that  felt  in  the  expulsive  efforts  of  a  patient  with  hernia 
may  be  appreciated. 

Exploration  by  the  vagina,  when  the  capacity  of  this  tube  will  permit,  will  aid 
in  diagnosis. 

When  the  intestine  opens  into  another  hollow  organ,  or  through  the  integument 

476 


RECTUM  AND   ANUS 


477 


in  an  abnormal  position,  the  only  diagnostic  sign  is  the  presence  of  fecal  matter 
in  the  natural  discharge  from  the  organ  or  at  the  abnormal  opening.  In  atresia 
recti  in  female  children,  the  bowel  opens  most  frequently  into  the  uterus  or  vagina, 
and  in  males  into  the  bladder.    At  times  the  communication  is  established  between 


Fig.  499. — Atresia  of  the  anus  and  rectum. 
(After  Esmarch.) 


Fig.  500. — Atresia  of  tlie  anus  and  lower  portion 
of  the  rectum;  the  upper  part  opening  into 
the  urethra.     (After  Ksmarch.) 


the  bowel  and  the  urethra,  or  a  false  opening  may  occur  at  any  point  m  the  peri- 
nseum,  and,  in  rarer  cases,  in  some  remote  portion  of  the  body. 

Treatment. — The  indications  are  to  establish  an  opening  as  near  the  natural 
position  of  the  anus  as  possible.  If  the  blind  pouch  can  be  reached  by  the  exploring 
aspirator,  the  needle  should  be  left  in  place  as  a  guide.  The  operative  procedure 
is  to  dissect  gradually  toward  the  supposed 
location  of  the  end  of  the  gut,  keeping  an 
open  and  clear  wound  by  using  retractors 
and  arresting  all  hjemorrhage.  The  inci- 
sion through  the  integument  should  he  in 
the  median  line,  with  its  center  just  in 
front  of  the  tip  of  the  sacrum  and  coccyx, 
for,  if  the  spliincier  ani  is  present  even  in 
an  imperfect  condition,  it  is  important  to 
preserve  it  to  aid  in  the  voluntary  control 
of  the  bowel  when  the  operation  is  com- 
pleted. When  there  exists  only  a  thin 
septum,  this  muscle  is  usually  well  devel- 
oped, and  the  operation  is  a  simple  incision 
and  di\atlsion  of  the  membrane.  In  more 
formidable  operations,  the  location  of  the 
urethra  and  bladder,  and  in  females  the 
vagina  and  uterus,  must  be  kept  well  in 
mind,  for  in  infants  the  jDclvic  diameters 
are  very  small,  varying  from  one  to  one 
and  a  half  inch.  It  is  a  safe  rule  to 
proceed  cautiously  along  the  sacral  curve. 

Moreover,  it  is  wiser  to  dispense  with  an  anaesthetic,  since  the  expulsive  efforts 
in  crying  may  aid  in  finding  the  end  of  the  gut. 

When  it  is  reached,  if  it  is  possible,  the  end  should  be  loosened,  drawn  down, 
and  sutured  to  the  integument  of  the  edges  of  the  incision.  If  this  is  not  done, 
the  opening  usually  contracts,  necessitating  repeated  dilatation  by  the  use  of  the 


1.  501. — The  same;  tlie  upper  portion  of  the 
rectum  opening  into  the  bladder.  (After 
Esmarch.) 


478  EECTUM   AND   ANUS 

finger,  tents,  or  a  divulsor.  In  some  instances  it  has  been  found  necessary  to 
remove  tlie  coccyx  in  order  to  effect  tlie  union  of  the  bowel  with  the  skin. 

When,  after  proceeding  as  far  as  the  immediate  safety  of  the  infant  will  justify, 
the  bowel  cannot  be  discovered,  the  propriety  of  colostomy  or  enterostomy  may  b& 
entertained.  When  the  intestine  ends  directly  in  the  uterus  or  vagina,  and  there 
is  no  pouching  behind  these  organs  toward  the  perinseum,  it  is  best  not  to  inter- 
fere. If,  however,  the  bladder  or  urethra  is  involved,  an  opening  should  be  made 
or  colostomy  performed. 

In  exceptional  eases  the  anus  is  present  in  a  condition  of  more  or  less  perfect 
development,  while  at  the  same  time  the  rectum  does  not  communicate  with  it, 
but  terminates  in  a  blind  pouch  at  a  varying  distance  from  the  perinseum. 

Tlie  effort  should  be  made  to  establish  a  communication  between  the  two  pockets 
by  dissection  through  the  tissues  which  intervene. 

When  the  opening  from  the  rectum  is  abnormally  small  (a  congenital  stricture), 
dilatation,  incision,  or  divulsion  should  be  performed. 

The  prognosis  in  all  these  cases  is  unfavorable.  Inflammation,  visceral  com- 
plications, dilatation  of  the  bowel  above  with  retained  ingesta,  insufficient  assimila- 
tion, pain,  etc.,  render  a  fatal  issue  exceedingly  probable. 

Pruritus  Ani. — Persistent  itching  about  the  anus  may  be  caused  by  a  variety 
of  skin  diseases,  as  eczema,  herpes,  pit}'riasis,  and  erythema,  or  by  irritation  of  the 
end  organs  of  the  sensory  nerves  from  overdistention  in  tlie  act  of  defecation. 
It  is  also  a  symptom  of  hfemorrhoids,  fissure  of  the  anus,  or  may  be  due  to  the 
presence  of  the  thread- worm  (ascaris  vermicularis).  The  character  of  the  itching 
is  burning,  jDainful,  and  aggravating,  and  the  desire  to  scratch  is  almost  irresistible. 
The  successful  management  of  pruritus  ani  will  depend  upon  the  recognition  of 
the  disease  of  which  it  is  a  symptom. 

Eczema  of  the  perinsBum  and  anus  is  more  apt  to  occur  in  a  warm  temperature, 
where  perspiration  is  excessive,  and  in  corpulent  individuals,  where  considerable 
friction  occurs  between  the  folds  of  integument  of  this  region.  The  skin  becomes 
infiltrated  and  thickened,  fissures  are  formed,  and  the  mucous  membrane  at  the 
anal  opening  may  become  involved. 

Treatment. — The  part  affected  should  be  kept  clean  and  friction  prevented  as 
much  as  possible.  In  the  acute  eczema  of  the  anal  region  a  warm  bath,  without 
soap,  should  be  taken  two  or  three  times  a  day,  the  parts  thoroughly  dried,  and 
sprinkled  with  powdered  starch  or  lycopodium.  If  excoriations  exist,  lead-and- 
opium  wash  should  be  tried.  In  chronic  eczema  of  the  anus,  in  order  to  effect  a 
cure,  it  is  often  necessary  to  remove  the  accumulation  of  scales  by  the  local  use 
of  green  soap  for  a  day  or  two,  and  then  smearing  the  surface  with  diachylon  salve. 

Herpes  may  be  recognized  by  the  character  of  the  eruption,  which  is  vesicular, 
the  vesicles  being  grouped  in  bunches  around  the  anus.  Those  which  rupture  and 
are  subjected  to  irritation  present  flat  and  slightly  ulcerating  excoriations.  The 
treatment  consists  in  thoroughly  washing  the  surface  involved  with  a  warm  solu- 
tion of  boracic  acid,  grs.  xv-gj  of  water,  by  means  of  pellets  of  absorbent  cotton 
moistened  in  the  solution.  This  should  be  followed  by  applying  an  astringent  oint- 
ment, composed  as  follows :  plumbi  acetatis,  grs.  iij ;  acid,  tannic,  gr.  j ;  morphiae 
suIjdIi.,  grs.  iij ;  adipis,  §j. 

Erytliema  is  a  mild  form  of  inflammation  of  the  integument,  occurring  here 
as  a  result  of  friction  between  the  folds  of  skin  of  the  two  sides  and  the  irritation 
from  perspiration  or  other  fluids.  The  warm  bath,  followed  by  sprinkling  the  part 
affected  with  starch  or  lycopodium,  will  usually  effect  a  cure. 

Pityriasis  versicolor  occasionally  exists  in  the  ischio-rectal  region.  This  disease 
can  be  recognized  by  the  brownish  slate  color  of  the  parts  involved.  The  cause 
is  a  vegetable  parasite,  the  spores  and  mycelia  of  which  may  be  easily  recognized 
by  the  microscope.  It  yields  readily  to  pure  sulphurous  acid,  which  may  be 
applied  by  means  of  a  camel's-hair  pencil.  Corrosive  sublimate  (gr.  j  to  water  §j) 
may  be  applied  by  mopping  with  absorbent  cotton  dipped  in  this  solution. 

AVhen  pruritus  occurs  with  haemorrhoids  or  fissures,  the  treatment  must  be 
directed  to  these  affections.  If  it  is  caused  by  overdistention  or  irritation  of  the 
rectum  and  anus,  the  use  of  enemata  and  laxatives  will  arrest  the  disease.     The 


RECTUM   .^'D   A^'US 


479 


local  application  of  a  four-per-cent  solution  of  cocaine  hydrochlorate  ■n"ill  dull  the 
sensibility  of  the  part  and  temporarily  stop  the  pain  and  itching. 

Ascarides,  or  '"  thread-worms,"'  are  not  an  uncommon  cause  of  pruritus  and. 
They  vary  in  length  from  a  quarter  to  half  an  inch,  are  someivhat  lighter  in  color 
than  the  mucous  membrane,  and  are  not  readily  seen  unless  this  membrane  is 
everted  and  carefully  examined.  Santonin  in  full  doses  should  be  administered 
for  two  or  three  days,  followed  by  a  free  purgation.  When  this  is  accomplished 
the  bowel  should  be  distended  with  an  enema  of  lime-water,  retained  for  fifteen 
minutes,  if  possible,  and  repeated.  As  soon  as  the  last  injection  is  evacuated,  a 
pint  of  water,  in  which  grs.  sx  of  carbolic  acid  are  thoroughly  dissolved,  should 
be  thrown  into  the  rectum  and  retained  for  about  five  minutes.  The  injection  of 
lime-water  and  carbolic  acid  in  solution  should  be  repeated  for  several  days  to 
insure  a  thorough  destruction  of  these  annoying  parasites. 

Enemata  of  the  infusion  of  quassia  are  also  highly  recommended  in  the  exter- 
mination of  the  ascaris  vermicularis. 

Foreign  Bodies. — Foreign  bodies  in  the  rectum  are  usually  introduced  through 
the  anus,  and  not  infrequently  lodge  here,  having  passed  through  the  alimentary 
canal.  Their  presence  may  be  recognized  by  digital  exploration,  or,  when  of  small 
size,  the  speculum  may  be  employed. 

Digital  exploration  of  the  rectum  may  be  performed  with  the  minimum  of 
discomfort  by  curving  the  thoroughly  lubricated  finger  to  conform  to  the  shape 
of  the  lower  portion  of  the  bowel.  The  direction  from  the  anus  is  upward  and 
forward  for  the  first  inch  and  a  half,  and  then  upward  and  slightly  backward. 

If  a  speculum  is  employed,  that  of  Sims  (Fig.  502)  should  be  preferred. 


ims'  rectal  speculum. 


A  small  body  may  be  readily  removed  by  seizing  it  with  a  long  forceps  after 
dilatation  with  this  tastrument.  A  large  substance  may  recjuire  ansesthesia,  with 
forcible  divulsion  of  the  sphincter,  or  a  posterior  linear  rectotomy  before  it  can 
be  removed.  When  the  object  is  made  of  glass  or  any  fragile  substance,  great  care 
should  be  taken  to  prevent  its  breakiag. 

Fistula  in  Ano. — A  fistula  of  the  anus  or  rectum  may  be  complete  or  incom- 
plete. The  last  variety  is  further  divided  into  the  incomplete  external  and  the 
incomplete  internal  fistula. 

In  the  complete  form  the  track  of  the  fistula,  more  or  less  sinuous,  leads  from 
the  wall  of  the  rectum  or  the  anal  margin  out  through  the  integument  of  the 


Fig.  503. — Complete  fistula 
in  recto. 


Fig.  504. — Incomplete  exter- 
nal fistula. 


Fig.  505. — Incomplete 
internal  fistula. 


perineal,  isehio-rectal,  or  gluteal  regions   (Fig.  .503).     In  the  incomplete  external 
variety,  the  track  opens  through  the  skin,  but  does  not  communicate  with  the 


480  RECTUM  AND   ANUS 

rectum  (Fig.  504);  while  in  the  incomplete  internal  fistula. the  track  opens  into 
the  bowel  only  (Fig.  505). 

Causes. — The  loose  areolar  tissue  which  surrounds  the  lower  portion  of  the 
rectum  possesses  a  low  vitalitj^  Its  nutrition  is  more  or  less  impaired  by  over- 
distention  of  the  bowel,  which  renders  it  a  suitable  nidus  for  the  lodgment  and 
proliferation  of  infectious  organisms.  If  these  do  not  find  their  way  here  through 
the  blood  channels,  they  may  readily  effect  entrance  by  the  lymphatic  channels 
which  communicate  with  abrasions  (fissures,  ulcerating  ha?morrhoids),  etc.,  which 
are  common  near  the  anal  aperture.  It  is  rarely  by  direct  perforation  of  the  bowel 
wall  that  infection  occurs. 

A  not  infrequent  source  of  infection  is  the  bacillus  tuberculosis.  As  is  well 
known,  this  organism  is  not  pyogenic,  nor  does  it  produce  inflammation  of  a  painful 
nature,  nor  any  recognizable  exacerbations  of  temperature  unless  a  mixed  infection 
occurs  and  pus  is  produced.  Whenever  suppuration  takes  place,  whether  tubercu- 
losis be  present  or  not,  pain  is  a  jDrominent  symptom,  and  there  is  a  marked  febrile 
movement.  As  the  pus  accumulates  the  tissues  break  down,  and  the  abscess  opens 
into  the  bowel  or  through  the  integument.  A  compilete  fistula  may  be  developed 
from  either  of  the  incomplete  varieties  by  partial  occlusion  of  the  original  opening, 
thus  causing  the  f>us  to  seek  an  outlet  elsewhere. 

Abscess  of  this  region  may  be  superficial  or  deep.  When  superficial,  it  is  apt 
to  oijen  through  the  mucous  membrane,  just  above  the  junction  of  the  skin  and 
mucous  membrane.  When  the  deep  variety  opens  into  the  rectum,  it  is  usually  at 
a  point  from  three  fourths  of  an  inch  to  two  inches  from  the  margin  of  the  anus. 
A  single  abscess  may  have  one  or  more  openings  into  the  rectum  or  through  the 
skin. 

The  diagnosis  of  fistula  in  ano  is  not  difficult.  It  depends  upon  the  history 
of  an  abscess  followed  bv  a  constant  or  frequently  recurring  discharge  of  pus,  the 
pain  being  severe  until  fhe  abscess  is  evacuated,  and  recurring  in  a  varying  degree 
with  the  temporary  closure  of  the  outlet.  An  area  of  induration  usually  exists, 
and  the  opening  may  be  discovered  either  through  the  skin  or  within  the  anus. 
If  an  external  opening  exists  through  which  gas  or  fecal  matter  escapes,  a  com- 
plete fistula  is  demonstrated.  When  an  external  opening  is  formed,  imless  the 
abscess  is  very  recent,  there  is  almost  always  an  internal  opening,  although  it  may 
not  be  found.  The  diagnosis  may  be  further  made  clear  by  exploration  with  the 
probe,  an  operation  which  is  rendered  practically  painless  by  the  injection  of  a 
two-per-cent  solution  of  cocaine  hydrochlorate  into  the  abscess  cavity.  If  a  single 
injection  does  not  sufficiently  dull  the  sensibility,  it  should  be  repeated. 

No  matter  where  the  external  opening  is  situated,  the  track  will,  in  the  great 
majority  of  instances,  run  just  beneath  the  skin  toward  the  anus.  The  probe  should 
be  allowed  to  find  its  own  way,  and  when  well  in,  the  point  at  which  it  impinges 
upon  or  opens  into  the  bowel  can  be  determined  by  the  finger  in  the  rectum. 

Treatment. — When  seen  early,  a  perirectal  infection  or  beginning  abscess  should 
be  incised  (not  punctured)  and  drained  by  loosely  packing  it  with  a  ribbon  of 
gauze.  The  incision  can  be  made  with  cocaine  infiltration.  •  In  the  early  stages 
there  is  very  rarely  any  communication  with  the  bowel,  and  the  majority  of  such 
cases  can  be  cured  in  this  stage.  If,  however,  the  formation  of  pus  is  extensive, 
and  the  loose  areolar  tissue  has  been  dissolved  or  dissected  up  until  a  large  pocket 
is  formed,  it  is  extremely  difficult  to  effect  a  cure  without  performing  a  more 
radical  operation.  Should  circumstances  necessitate  postponement  of  the  thorough 
procedure,  the  incision  and  drainage  should  be  done  immediately.  Tuberculous 
fistulse  may  exist  without  pyogenic  infection,  and  often  with  very  insignificant  pain. 
The  operative  treatment  of  this  variety  is  practically  the  same  as  that  to  be  given 
for  the  radical  cure  of  fistula  in  ano. 

Operation. — A  laxative  should  be  administered  and  the  Ijowels  thoroughlj^  emp- 
tied the  day  before  the  operation.  The  perinasum  and  region  of  the  anus  should 
be  cleanly  shaved.  The  patient  shoiild  be  placed  upon  the  back,  with  the  sacrum 
resting  on  the  edge  of  the  table,  the  legs  fiexed  on  the  thighs,  and  the  thighs  on 
the  abdomen,  and  separated ;  or  upon  the  side  in  the  Sims  position.  The  probe 
sho^^ld  be  carried  into  the  fistula,  the  lubricated  index-finger  of  the  left  hand  into 


RECTUM   AND  ANUS  481 

ilie  rectum,  and  the  point  noted  at  which  the  instrument  strikes  the  rectum.  The 
prolje  is  now  withdrawn  and  the  grooved  director  introduced  in  the  same  trade. 
If  the  opening  into  the  bowel  cannot  be  found,  tlie  operator  sliould  determine  by 
the  touch  tlie  thinnest  point  on  the  intervening  wall,  and  at  this  location  bore 
through  into  the  rectum,  supporting  the  mucous  memlirane  near  the  point  of  the 
instrument  with  the  finger  in  tlie  bowel.  As  soon  as  the  director  is  felt  in  the 
cavity  of  the  gut,  the  point  should  be  brought  out  at  the  anus,  the  sharp-pointed 
curved  bistoury  carried  along  the  groove,  and  the  fistula  laid  open  by  dividing  the 
intervening  bridge  of  tissue.  If  a  second  sinus  exists,  it  should  be  incised  in 
the  same  way,  but  it  is  always  advisable  to  make  only  a  single  incision  through  the 
sphincters.  The  bleeding  is  usually  insignificant,  and  may  be  arrested  by  pressure, 
or  the  ligature.  The  finger  should  now  be  carried  into  the  wound,  and,  if  it  is 
discovered  that  the  abscess  extends  higher  along  the  wall  of  the  rectum  than  the 
point  at  which  the  director  was  carried  through,  the  intervening  wall  should  be 
divided  with  the  blunt  scissors.  It  is  important  that  the  incision  in  the  gut 
should  extend  to  the  depth  of  the  abscess  when  this  point  is  less  than  three  inches 
from  the  anus.  A  careful  search  for  any  pockets  or  sinuses  should  be  made,  and 
these,  if  found,  should  be  laid  freely  open.  The  fistulous  tract  and  abscess  wall 
should  be  thoroughly  scraped  out  with  the  Volkmann  sharp  spoon,  or  the  indurated 
and  infected  lining  membrane  dissected  out  with  curvect  scissors  or  scalpel.  In 
tuberculous  infiltration,  in  order  to  effect  a  cure,  it  is  essential  that  all  the  tissues 
invaded  by  the  tubercular  bacilli  be  thoroughly  removed.  The  entire  wound  should 
be  packed  with  plain  sterile  gauze,  held  in  place  by  a  compress  of  absorbent  cotton 
and  a  T-bandage.  This  dressing  should  be  allowed  to  remain  in  place  for  two 
or  three  days,  when,  with  the  first  evacuation  of  the  bowels,  it  is  carried  away. 
After  this  the  wound  is  not  repacked,  but,  for  purposes  of  cleanliness,  it  may  be 
w^ashed  out  by  allowing  the  patient  to  sit  in  a  basin  of  warm  water  once  or  twice 
a  day,  or  by  irrigation,  and  an  outside  dressing  applied. 

The  wound  rapidly  heals  by  granulation,  and,  in  the  vast  majority  of  cases,  a 
cure  is  effected  by  a  single  operation.  Temporary  incontinence  of  faeces  results 
in  all  cases  where  both  sphincters  are  divided,  but  a  permanent  loss  of  function 
is  exceptional.  It  is  more  apt  to  occur  in  females,  and  for  this  reason  a  more 
guarded  prognosis  should  be  made  in  this  class  of  patients.  In  the  rare  instances 
in  which  an  internal  incomplete  fistula  is  present,  the  cavity  of  the  abscess  should 
be  opened  hj  incision  through  the  skin,  and  the  operation  completed  as  just  given. 

A  division  of  the  external  sphincter  is  not  necessary  in  the  mildest  class  of 
cases,  in  which  the  abscess  is  recent  and  small,  and  in  which  the  sinus  runs  just 
beneath  the  skin  and  opens  at  the  margin  of  the  anus.  Under  all  other  conditions 
it  should  be  partially  or  completely  divided. 

Prophylaxis. — Upon  the  first  appearance  of  inflammation  in  the  ischio-rectal  or 
perineal  region,  the  integument  immediately  over  the  most  superficial  point  of  the 
induration  should  be  incised,  and  a  free  puncture  made  into  the  inflamed  tissues. 
This  should  be  followed  by  the  insertion  of  a  small  packing  of  gauze,  which  should 
be  changed  daily.  Too  great  distention  of  the  rectum  should  be  prevented  by  the 
administration  of  laxatives,  and  an  enema  of  warm  water  should  be  given  just 
before  the  bowel  is  emptied.  By  this  method  the  tension  is  relieved  and  an  outlet 
given  to  the  jDroducts  of  inflammation  before  the  process  extends  into  the  deeper 
tissues.  A  cure  without  further  operation  will  be  effected  in  a  fair  proportion 
of  cases. 

After  an  abscess  is  once  formed,  whether  the  fistula  oiDcns  into  the  rectum  or 
through  the  integument,  or  has  both  outlets,  the  case  demands  operative  inter- 
ference. The  proportion  of  cures  by  the  use  of  injections  into  the  fistula,  or  the 
application  of  stimulating  remedies,  is  very  small.  Of  the  radical  operations,  pref- 
erence should  always  be  given  to  that  of  free  incision.  The  elastic  ligature  should 
only  be  tried  on  patients  who  are  unwilling  to  remain  in  bed,  or  to  be  operated  upon 
with  the  knife,  to  whom  the  merits  of  the  two  operations  have  been  explained,  and 
■who  relieve  the  surgeon  of  the  jDrobabilities  of  failure.  It  is  also  applicable  to  those 
cases  in  which  the  fistula  enters  the  rectum  so  high  up  that  incision  is  impracticable. 
A  guarded  jprognosis  should  be  made  in  this  class  of  patients. 


482  RECTUM   AND   ANUS 

Operative  interference  is  contra-indicated  in  multiple  fistula  in  the  aged,  or  in 
patients  in  a  weak  and  debilitated  condition.  When  the  tubercular  diathesis  is 
well  marked,  an  operation  should  not  be  done  unless  great  discomfort  is  caused  by 
the  fistula,  and,  when  performed,  the  prognosis  should  be  guarded. 

Fissure. — Fissure  of  the  anus  is  most  frequently  met  with  on  the  posterior  por- 
tion of  the  outlet.  It  may,  however,  exist  at  any  part  of  the  anal  circumference,  or 
in  the  rectum  above  the  sphincter.  The  tear  is  usually  through  the  mucous  mem- 
brane, although  the  muscular  fibers  may  be  more  or  less  involved.  The  chief  cause 
is  overdistention  of  the  anus  in  the  evacuation  of  hardened  fseces,  together  with 
the  presence  of  sharp  substances  in  the  matter  discharged.  In  like  manner,  foreign 
bodies  introduced  into  the  rectum  may  produce  it.  Fissure  may  result  from  the 
inflammation  and  ulceration  of  a  hfemorrhoid,  or  from  any  chronic  inflammatory 
process  in  the  rectum. 

The  chief  symptom  is  pain  of  an  acute  character,  exaggerated  by  an  evacuation 
of  the  bowel,  and  continuing  some  time  after  the  act  in  a  violent  spasm  of  the 
sphincter  muscle.  By  careful  and  gentle  dilatation  of  the  anus,  it  may  be  seen 
or  recognized  by  the  touch  as  a  line  of  induration  running  parallel  with  the  axis 
of  the  bowel.  The  employment  of  cocaine  will  render  the  exploration  more  thor- 
ough, and  will  permit  the  introduction  of  the  speculum. 

Treatment. — The  administration  of  laxatives,  and  the  employment  of  enemata 
of  warm  water  and  olive  oil,  will  remove  the  chief  source  of  irritation,  while  the 
stimulating  effect  of  the  lunar-caustic  pencil  applied  in  the  fissure,  and  repeated 
every  two  or  three  days,  will  usually  efl'ect  a  cure.  Cocaine  should  be  employed 
to  deaden  the  sensibility  before  the  silver  is  applied.  If  a  more  radical  procedure 
is  necessary,  it  will  consist  in  a  division  of  the  sphincter  in  the  line  of  the  fissure, 
as  advised  by  Prof.  S.  G.  Gant. 

The  patient,  previously  prepared,  is  placed  upon  a  low  table  in  the  lithotomy 
position.  The  operator  seizes  a  fold  of  skin  in  the  median  line  one  inch  posterior 
to  the  anal  margin,  and  compresses  it  between  the  thumb  and  finger,  to  lessen 
the  pain  of  puncture.  In  hypersensitive  cases,  a  momentary  spray  with  a  Richard- 
son ether  atomizer  will  render  the  puncture  and  instillation  of  the  cocaine  solution 
entirely  painless.  The  weak  solution  is  used,  as  heretofore  directed  (see  local 
ansesthesia).  The  anal  circumference  on  either  side  of  the  fissure  and  proposed 
line  of  incision  should  be  infiltrated,  and  the  tissues  immediately  adjoining  the 
fissure  well  anagsthetized.  The  anaasthesia  should  extend  along  the  rectal  wall  in 
the  line  of  incision  for  at  least  one  and  a  half  inches.  Gant  emphasizes  the  fact 
that  it  is  a  waste  of  time  to  try  to  locate  the  sensory  nerves,  since  perfect  anaesthesia 
is  everywhere  obtained  by  the  infiltration.  In  the  track  of  the  fissure  an  incision 
is  now  made  to  the  depth  of  about  one  half  inch,  dividing  the  skin,  subcutaneous 
structures,  posterior  bowel  wall,  and  sphincter.  Any  skin  tags  or  jjiles  should  be 
excised,  and  the  wound  lightly  packed  with  sterile  gauze,  to  prevent  bleeding.  It 
is  then  covered  by  a  gauze  pad,  kept  in  place  by  -a  T-bandage,  well  adjusted. 

The  post-operative  treatment  consists  in  cleansing  the  wound  daily  after  each 
stool,  and  inserting  a  piiece  of  gauze  loosely  in  the  cut  as  a  drain  and  to  keep  the 
edges  apart.  .  After  the  first  week  the  gauze  is  moistened  with  ichthyol  or .  balsam 
of  Peru.     The  patients  are  at  no  time  confined  to  bed. 

Ulcers. — The  traumatic  causes  of  ulcer  of  the  rectum  are  the  same  as  those 
given  for  fissure  of  the  anus.  Ulcer  may  also  result  from  any  acute  or  chronic 
inflammatory  process  of  the  lower  bowel.  It  is  a  not  infrequent  sequence  of  dys- 
entery, and  may  be  met  with  in  that  form  of  proctitis  which  results  from  prolonged 
diarrhffia.  Inflammation  of  a  hemorrhoidal  tumor  will  produce  ulcer  of  the  lower 
portion  of  the  rectum,  and  the  same  is  true  of  the  gummatous  deposits  of  the  late 
stages  of  syphilis.  A  primary  chancre  or  a  chancroid  may  be  located  at  the  anal 
margin,  and  less  frequently  in  the  bowel.  These  two  varieties  of  ulcer  are  usually 
seen  in  women  suffering  with  pudendal  chancre  or  chancroid.  Tubercular  deposits 
in  the  rectum  may  also  break  down,  and  thus  cause  ulceration  in  the  wall  of 
this  organ. 

The  symptoms  of  ulcer  of  the  rectum  vary  with  the  character  of  the  sore  and 
with  its  location.     If  the  lesion  is  situated  within  the  grasp  of  the  sphincter  mus- 


RECTUM   AND  ANUS  483 

cles,  tenesmus  is  apt  to  be  a  marked  feature.  The  ulcer  from  a  traumatism,  or 
following  an  acute  inflammatory  process,  is  more  apt  to  be  painful  than  that  which 
is  a  part  of  a  subacute  or  chronic  catarrh,  or  which  occurs  witli  tuberculosis  or 
syphilis.  A  common  symptom  of  all  ulcers  of  this  organ  is  the  presence  of  more 
or  less  blood  and  mucus  or  pus  in  the  discharges.  The  diagnosis  may  be  confirmed 
by  inspection  with  the  speculum,  and  by  digital  exploration.  Rectal  illumination 
by  reflected  light  or  preferably  by  the  electric  proctoscope  of  Prof.  James  P.  Turtle, 
is  a  valuable  aid  to  correct  diagnosis  of  ulcer,  stricture,  neoplasm,  or  other  lesions 
of  the  sigmoid  flexure  or  rectum.  Tubercrilar  ulcer  of  the  rectum  very  rarely 
exists  before  the  symptoms  of  deposits  in  the  lungs  are  present.  Upon  inspection 
they  are  recognized  by  their  yellowish  color,  usually  small  size,  and  their  dissem- 
ination over  a  considerable  area  of  the  mucous  membrane.  In  the  more  fully 
developed  ulcers  the  caseous  degeneration  of  the  inflammatory  products  may  be 
observed. 

Mr.  AUingham  describes  a  rare  form  of  ulcer  which  he  has  occasionally  ob- 
served in  the  rectum,  and  which  he  has  named  lupoid,  or  rodent  ulcer,  of  this 
organ.  Its  usual  location  is  near  the  anus.  It  tends  to  spread  widely,  the  floor 
of  the  ulcer  is  red  and  dry,  the  margins  irregular  and  precipitous.  It  is  very 
probably  tubercular  in  character. 

Chancroidal  ulcer  of  the  rectum  may  be  recog-nized  by  the  precipitous  margins 
of  these  sores,  and  by  the  rapidity  with  which  they  spread.  In  patients  aifected  with 
phagedenic  ulcers  of  the  genital  organs,  the  inoculation  may  occur  by  direct  contact 
of  the  secretion  of  the  venereal  sore,  or  the  virus  may  be  conveyed  through  the 
medium  of  the  nails  in  the  act  of  scratching.  Under  such  conditions  the  sore 
usually  first  appears  upon  the  mucous  membrane  of  the  margins  of  the  anus,  and 
extends  later  into  the  rectum.  The  diagnosis  must  be  based  upon  the  peculiar 
appearance  of  the  ulcer,  together  with  the  probabilities  of  infection  from  a  con- 
tiguous venereal  ulcer. 

The  hard  syphilitic  or  true  chancre  is  rarely  observed  in  this  region,  and,  when 
met  with,  is  usually  confined  to  the  anal  margin.  It  possesses  here  the  same  well- 
recognized  features  of  the  specific  ulcer  of  the  genital  organs,  from  which  source 
the  virus  is  conveyed  usually  by  the  nails,  and  occasionally  by  immediate  contagion. 

Ulcers  of  the  rectum  resulting  from  the  breaking  do-wn  of  the  gummatous  de- 
posits of  tertiary  syphilis  are  chiefly  seen  just  along  the  upper  margin  of  the 
sphincter  muscle.  From  this  point  they  extend  upward,  and  may  involve  the  entire 
rectum  and  invade  the  colon.  These  ulcers  are  usually  multiple,  varying  in  size 
from  a  small  point  to  a  half  inch  or  more  in  diameter,  and  in  depth  may  involve 
only  the  mucous  membrane,  or  the  muscular  and  connective-tissue  stroma  may  be 
destroyed,  and  in  some  instances  perforation  may  occur.  The  process  of  destruc- 
tion is  greater  in  the  older  ulcers,  and  the  various  stages  may  be  observed  by 
examining  the  bowel  from  below  upward.  The  appearance  of  the  ulcers  as  above 
describedr  together  with  the  history  of  syphilis,  will  enable  the  observer  to  arrive 
at  a  correct  diagnosis.  Traumatic  ulcers,  and  those  resulting  from  the  breaking 
down  of  hajmorrhoidal  tumors,  will  be  recognized  by  the  appearance  of  the  sore 
and  the  history  of  an  accident  or  haBmorrhoids. 

As  far  as  a  cure  of  the  ulcer  is  concerned,  a  favorable  prognosis  may  be  made 
in  all  ulcers  of  the  rectum  except  the  tubercular.  These  may  be  relieved  by  treat- 
ment, but,  being  expressions  of  an  incurable  dyscrasia,  permanent  relief  cannot 
be  expected.  A  more  remote,  as  well  as  greater  evil  which  often  results  from  ulcer 
is  stricture  of  the  rectum,  and  the  danger  of  stricture  is  usually  proportionate  to 
the  extent  of  the  destructive  process.  Phagedenic  chancroidal  ulcer,  and  the  ulcers 
of  gumma  and  dysentery,  are  especially  prone  to  induce  stricture. 

Treatment. — The  common  indication  in  the  treatment  of  all  forms  of  iilcer  of 
the  rectum  is  to  keep  the  bowel  in  as  complete  repose  as  possible.  Every  effort 
should  be  made  to  keep  it  clear  of  fecal  matter.  This  may  be  accomplished  by 
the  repeated  employment  of  enemata,  and  liy  the  administration  of  proper  articles 
of  diet,  all  of  which  shoidd  be  capable  of '  absorption  in  the  stomach  and  small 
intestines.  Milk,  meat  juice,  soft-boiled  eggs,  rice,  wheatena,  corn-meal  mush, 
etc.,  will  afford  variety  and  sustain  the  patient's  nutrition. 


484  RECTUM  AND   ANUS 

In  irrigation  of  the  diseased  surface,  warm  or  cold  water  may  be  used  at  the 
temperature  which  is  most  agreeable  to  the  patient.  The  best  apparatus  for  this 
purpose  is  the  fountain  syringe.  The  smallest  glass  nozzle,  thoroughly  warmed 
and  oiled,  should  be  employed,  and  from  one  to  two  pints  of  fluid  may  be  intro- 
duced at  one  injection.  A  larger  quantity  may  be  employed  when  the  colon  is 
involved.  If  the  patient  is  placed  upon  the  left  side,  with  the  buttocks  elevated, 
a  greater  degree  of  tolerance  will  be  obtained  in  the  rectum.  The  fluid  should  be 
retained  for  a  few  minutes,  if  possible.  In  obstinate  cases  which  resist  all  ordinary 
means,  appendicostomy  and  irrigation  from  the  cfficum  is  indicated. 

When  the  ulcer  encroaches  upon  the  sphincter  muscle,  causing  painful  tenes- 
mus, the  hypodermic  use  of  morphia  or  opium  suppositories  may  be  required  to 
relieve  the  spasm.  In  obstinate  cases  divulsion  or  division  of  the  sphincter  may 
be  done  as  a  last  resort. 

In  the  treatment  of  the  ulcers  which  result  from  dysentery,  catarrh  of  the 
rectum,  an  injury,  or  breaking  down  of  hemorrhoids,  the  plan  just  given  should 
be  adopted.  It  is  often  advisable  to  add  from  grs.  v-x  of  nitrate  of  silver  to  the 
pint  of  water  thrown  in,  and,  if  the  ulcer  can  be  reached,  recovery  will  be  hastened 
by  the  local  use  of  the  lunar  caustic.  An  excellent  remedy  for  the  alleviation  of 
pain  and  the  relief  of  tenesmus  is  a  suppository  composed  of  gr.  ij  each  of  iodoform 
and  cocaine  hydrochlorate,  introduced  from  three  to  five  times  in  twenty-four 
hours.  As  already  stated,  in  obstinate  and  extreme  cases,  colostomy  may  be 
necessitated. 

Chancroidal  ulcer  of  the  rectum  requires  the  most  energetic  treatment.  Ether 
should  be  administered,  the  sphincter  divulsed,  the  ulcer  exposed  by  the  speculum, 
its  surface  scraped  with  the  curette,  and  a  tliorough  cauterization  effected  with 
nitric  acid.  The  cocaine  and  iodoform  suppositories  should  be  employed  in  the 
after-treatment. 

True  syphilitic  chancre  of  the  rectum  rarely  demands  local  treatment.  It 
yields  readily  to  the  constitutional  remedies  employed  in  syphilis. 

The  specific  ulcer  of  the  later  stages  of  syphilis  requires  the  constitutional 
treatment  recommended  for  the  late  manifestations  of  this  disease,  and,  locally, 
irrigation  and  the  cocaine  and  iodoform  suppositories. 

Tubercular  ulcers  should  be  treated  chiefly  by  the  administration  of  cod-liver-oil 
emulsions,  the  iron  tonics,  the  hypophosphites  of  lime  and  soda,  and  carefully  se- 
lected diet.  Irrigation  with  warm  water  will  be  found  useful.  When  j^ain  and 
tenesmus  exist,  relief  may  be  obtained  by  the  means  already  given. 

In  rodent,  or  lupoid  ulcer,  the  Paquelin  cautery  knife  should  be  employed,  and 
a  thorough  excision  of  the  diseased  surface  effected. 

Stricture  of  the  Bectum. — Stricture  of  the  rectum  may  be  congenital  or  ac- 
quired. Partial  and  complete  congenital  occlusion  of  this  organ  has  already  been 
considered.  Acquired  stricture  is  usually  the  result  of  an  inflammatory  process 
in  the  walls  of  the  rectum,  and  at  times  in  the  tissues  which  surround  this  organ 
(Fig.  506).  ISTew  formations  (cancer,  etc.)  may  also  cause  a  partial  or  complete 
occlusion  of  the  rectum,  not  only  by  reason  of  the  bulk  of  the  cells  proper  of  the 
neoplasm,  but  on  account  of  the  inflammatory  process  which  it  causes  in  the  con- 
nective-tissue elements  of  the  bowel. 

The  lumen  of  this  portion  of  the  intestine  may  be  partially  or  completely  oc- 
cluded b}'  pressure  of  a  tuinor  not  connected  with  the  bowel,  or  by  the  presence  of 
some  displaced  organ,  as  the  uterus,  bladder,  etc.  Lastly,  spasmodic  ■  stricture  may 
occur  from  contraction  of  the  circular  muscular  fibers  of  the  rectum. 

As  stated  on  a  previous  page,  organic  stricture  frequently  follows  ulcer  of  the 
rectum,  and  is  especially  apt  to  occur  in  the  process  of  cicatrization  after  dysenteric 
ulcers  and  those  of  the  tertiary  stage  of  syphilis.  The  accidents  of  parturition 
not  infrequently  tend  to  stricture,  and  this  may  account  for  the  greater  prevalence 
of  this  lesion  in  females  than  in  males. 

Stricture  of  the  rectum  may  be  narrow  or  linear,  or  long  and  tortuous.  The 
usual  location  is  about  two  inches  above  the  margin  of  the  anus,  although  any  part 
of  the  organ  may  be  involved.  The  earlier  symptoms  of  this  lesion  are  interfer- 
ence with  the  act  of  defecation,  pain  with  the  passage  of  fajces,  and  the  presence 


RECTOI   .\XD   .AAT'S 


485 


of  blood  or  mucus  in  the  discharges.  In  some  instances  the  fjeces  are  tapelike,  or 
are  abnormally  shaped,  although  this  symptom  may  not  be  present  when  the  stric- 
ture is  liigh  up,  since  the  fecal  matter,  after  it  passes  through  the  constriction,  may 
assume  the  shape  of  the  bowel  below.  If  tlie  constriction  is  situated  within  the 
first  four  inches  of  the  bowel,  its  presence  and  caliber  may  be  determined  by  digital 
exploration.  \Yhen  with  difSculty  reached  bj'  the  finger,  the  patient  should  be 
directed  to  strain  as  if  at  stool,  in  order  to  force  the  obstruction  nearer  the  anus. 
Beyond  this  limit  tlie  bulbous  bougies  or  direct  illumination  and  the  sigmoid  specu- 
lum must  be  relied  upon.  The  bougies  are  of  all  sizes,  each  consisting  of  an  oval 
bulb  of  hard  rubber,  attached  to  the  end  of  a  flexible  whalebone  stail.  In  intro- 
ducing them  the  patient  should  rest  upon  the  back  while  the  bougie,  warmed  and 
oiled,  is  guided  up  the  bowel,  upon  the  index-finger  of  the  left  hand,  which  is 
carried  its  full  length  into  the  rectimi  (Fig.  507). 
If  resistance  is  met  with,  only  careful  and  gentle 
pressure  should  be  exercised,  for  undue  violence 
may  drive  the  bulb  through  the  wall  of  the  gut. 
The  inferior  limit  of  the  stricture  is  indicated  by 
the  first  obstraction  encountered.  If  the  bulb  can 
be  carried  throitgh  the  constriction,  the  resistance 
ceases,  but  is  again  experienced  when,  upon  with- 
drawing it,  the  shoulder  of  the  instrument  catelies 
at  the  upper  limit  of  the  obstruction.     The  lower 


Fig.  506. — Stricture  of  the  rectmn  from 
connective-tissue  new  formation  in 
the  submucous  layer.  (After  Buslie.) 


Fig.  507. — Method  of  introducing  the  bulbous  bougie  in 
exploration  of  the  rectum,     (.-\iter  Bushe.) 


border  of  the  stricture  is  again  indicated  when  all  resistance  ceases  in  withdrawing 
the  bulb. 

Treatment. — The  surgical  treatment  of  stricture  of  the  rectum  may  comprise 
dilatation  or  division  of  the  cicatricial  tissue  or  colostomy,  or  excision. 

The  character  of  the  obstruction  and  its  location  will  determine  the  means  to 
be  employed.  When  the  stricture  is  linear,  and  is  located  near  the  anus,  relief 
ma}'  be  obtained  by  dilatation.  For  this  purpose  the  finger  should  be  employed, 
and  the  operation  repeated  at  necessary  intervals  until  a  sttfficient  opening  is 
secured.  If  the  cicatricial  tissue  is  dense,  and  does  not  yield  in  the  effort  at  dila- 
tation, it  shotild  be  incised  to  a  slight  depth  at  four  or  five  points  of  its  circum- 
ference, and  the  finger  again  introduced.  The  incisions  may  be  made  with  a  probe- 
pointed  bistoury,  carried  along  the  finger  as  a  guide,  or  the  anus  and  bowel  may 
be  stretched  with  the  Sims  rectal  speculum  up  to  the  point  of  obstruction,  and 
the  Icuife  introdviced  without  a  guide.  If  this  procedure  is  not  successful,  the  only 
alternative  is  posterior  linear  rectotomy.  In  performing  this  operation  the  patient 
is  placed  upon  the  back,  with  the  anus  at  the  edge  of  the  table  and  the  legs  drawn 
up  and  separated.  The  parts  below  the  obstruction  are  dilated  with  the  speculum. 
A  long,  curved,  sharp-pointed  bistoury  is  carried  through  the  stricture,  keeping 


486  EECTTOI  AND  ANUS 

the  cutting  edge  toward  the  posterior  median  line  of  the  gut.  As  soon  as  the 
point  is  beyond  tire  obstruction,  hvt  not  more  than  four  inches  from  the  anus,  it 
is  carried  through  the  wall  of  tire  bowel,  which,  with  the  stricture,  is  completely- 
divided  out  through  the  anus.  If  the  irrst  incision  does  not  permit  the  introduction 
of  the  first  two  fingers  side  by  side,  it  should  be  made  deeper.  Haemorrhage  is 
readily  stopped  by  packing  the  woiind  and  bowel  with  gauze,  talving  the  precaution 
to  insert  a  stiff  rubber  tube  in  the  middle  of  the  dressing  to  allow  the  escape  of 
gas  from  the  intestine.  If  any  important  vessel  is  divided,  it  may  be  secured  with 
the  forceps  or  by  transfixation  with  a  tenaculum.  The  dressing  is  allowed  to  remain 
in  place  for  four  or  five  days,  and  is  not  replaced  after  the  bowels  are  moved  unless 
bleeding  should  occur.  Continence  of  fa?ces  is  restored  after  from  three  to  sis 
weeks.  No  matter  how  thoroughly  divided,  the  tendency  is  to  recurrence,  which 
necessitates  interrupted  dilatation  at  intervals  of  from  three  to  sis  weeks  during 
the  life  of  the  patient.  It  is  usually  not  necessary  to  practice  dilatation  within  the 
first  sis  or  eight  weeks  after  the  operation. 

When  the  stricture  is  situated  more  than  four  inches  above  the  anus,  proctotomy 
is  not  permissible  on  account  of  the  proximity  of  the  large  hsemorrhoidal  vessels, 
the  peritoneum,  and  pelvic  fascia.  Dilatation  with  the  soft-rubber  bougies  may 
be  tried,  and,  if  this  fails,  a  rectotomy  may  be  done  as  high  as  the  limit  already 
given,  which  will  allow  the  introduction  of  the  hand  to  this  point  and  the  finger 
into  the  stricture.  This  may  now  be  niclvcd  with  the  bistoury,  as  above  described, 
and  digital  or  instrumental  dilatation  effected.  Eectal  bougies  before  being  used 
should  be  made  thorouglily  flexible  by  immersion  in  M'arm  water.  In  their  em- 
ployment only  a  mild  degree  of  force  should  be  exercised,  for  fear  of  perforating 
the  wall  of  the  intestine. 

When  all  conservative  measures  fail,  exsection  with  end-to-end  union  should, 
if  possible,  be  done,  with  colostomy  as  the  last  resort. 

All  strictures  alcove  the  rectum  should  be  treated  by  celiotomy,  and  dealing 
directly  with  the  lesion  by  division  of  the  stricture  or  by  excision  and  anastomosis 
or  colostomy. 

Neoplasms  of  the  Eectum  and  Anus 

Carcinoma. — Of  the  malignant  new  formations  which  are  found  in  this  organ, 
epithelioma  is  the  most  common,  scirrlnis  and  encephaloid  cancer  being  next  in 
order  of  frequency.  The  latter  is  comparatively  rare.  Cancer  of  the  rectum  occurs 
about  equally  in  the  sexes,  and  almost  always  in  the  middle-aged  and  old,  although 
in  exceptional  instances  it  has  been  observed  before  the  age  of  twenty-five. 

Epithelioma  begins  in  the  mucous  membrane,  scirrhus  and  encephaloid  car- 
cinoma in  the  submucous  tissues. 

The  former  is  slower  in  development  and  less  apt  to  recur  after  removal.  The 
most  common  location  of  cancer  of  the  lower  bowel  is  at  the  upper  margin  of  the 
sphincter  muscle. 

The  prognosis  is  grave,  the  duration  of  life  varying  from  one  to  two  or  three 
3'ears,  and  in  excejitional  cases  longer.  Usually  the  earliest  symptom  of  cancer 
of  the  rectum  is  pain  with  the  act  of  defecation.  If  the  disease  is  located  at  the 
margin  of  the  anus,  it  can  be  recognized  before  there  is  any  interference  with 
the  discharge  of  fecal  matter.  Later,  hemorrhage  is  of  frequent  occurrence,  al- 
though, as  a  rule,  it  is  not  pirofuse  in  character.  After  an  evacuation  of  the  eon- 
tents  of  the  bowel,  the  pain,  though  less  intense,  remains  for  some  time.  A  sense 
of  fullness  or  ""  bearing  down  "  is  a  marked  feature  of  this  disease  in  the  majority 
of  cases. 

Diagnosis. — If  operative  interference  is  to  he  undertaken,  it  is  important  that 
an  early  diagnosis  be  made.  Epithelioma,  as  has  been  said,  begins  in  the  mucous 
membrane,  the  cells  of  the  new  formation  break  down  earh^,  the  ulcer  being  present 
in  some  instances  before  there  is  marked  induration.  On  the  other  hand,  indura- 
tion and  thickening  are  observed  early  in  the  history  of  scirrhus  and  encephaloid. 

Non-malignant  stricture  of  the  rectum  is  always  preceded  by  a  history  of  chronic 
inflammation.  To  the  touch,  the  cicatricial  character  of  the  tissue  may  be  recog- 
nized by  its  flrmness  and  sharp  borders.     It  is  not  nodular,  like  cancer,  nor  is 


RECTUM   AND   ANUS  487 

there  a  deep  and  wide  infiltration  of  tlie  surrounding  tissues  in  simple  stricture, 
"wliieli  condition  is  common  to  scirrhus  and  encejilialoid,  and  the  later  stages  of 
epithelioma.  In  doubtful  cases  it  will  be  advisable  to  remove  a  portion  of  the 
mass  for  microscopical  examination. 

The  treatment  of  cancer  of  the  rectum  may  be  palliative  or  radical.  The  former 
looks  to  the  prolongation  of  life  and  the  alleviation  of  pain  by  the  employment  of 
careful  dietetic  and  medicinal  measures.  The  regular  daily  introduction  of  warm 
.  water  will  prevent  the  lodgment  of  fecal  matter  and  secure  the  greatest  possible 
immunity  from  irritation.  The  iodoform  and  cocaine  suppositories  will  be  found 
useful  in  alleviating  pain,  and  morphia  may  be  employed  if  all  other  measures 
fail.  As  the  disease  progresses  it  will  be  found  necessary  to  practice  dilatation 
of  the  stricture  at  intervals  which  should  be  as  far  removed  as  possible,  or  partial 
or  complete  division  may  be  required. 

Colostomy  is  essential  in  the  palliative  treatment  of  carcinoma  of  the  rectum. 
In  forming  the  spur  for  a  permanent  artificial  anus  by  this  method,  in  order  to 
stiffen  it  the  mesenteric  attachment  should  l^e  left  between  the  two  rows  of  sutures. 
The  radical  cure  consists  in  the  free  excision  of  the  bowel  at  a  point  well  above 
the  tissues  involved  in  the  neoplasm.  Formerly  the  death-rate  after  this  operation 
was  exceedingly  heavy,  but  under  improved  methods  the  danger  is  materially  less- 
ened. The  important  question  to  be  decided  is  whether  the  operation  promises  well 
for  the  complete  cure  of  the  patient.  If  the  disease  is  limited  to  a  small  portion 
of  the  intestine,  which  condition  prevails  in  cases  seen  early,  the  diagnosis  may  be 
confirmed  by  excision  of  a  small  portion  under  cocaine  ana?sthesia,  for  microscopic 
study;  or  if  the  clinical  signs  point — as  those  do  in  most  cases  (ilathews) — to  the 
development  of  a  malignant  growth,  then  excision  should  be  undertaken  at  once, 
when  it  can  be  done  •nith  more  safety  to  the  patient  and  without  the  loss  of  enough 
bowel  to  interfere  too  seriously  with  the  function  of  the  alimentary  canal.  When 
the  disease  is  within  three  inches  of  the  anus,  and  there  is  no  infiltration  toward 
the  bladder  or  the  vaginal  wall  and  uterus,  excision  from  the  anal  approach  may 
be  undertaken.  Under  other  conditions  celiotomy  and  the  combined  operation,  as 
advised  by  Drs.  C.  H.  and  "W.  J.  Mayo,  and  already  given  in  Chapter  XXIII, 
may  be  done. 

Eeseciion  of  the  Bectum  from  the  Anal  Approach 

The  patient  is  prepiared  by  the  daily  administration  of  calomel  triturates  and 
saline  laxatives  for  three  or  four  days  before  the  operation.  Intestinal  asepsis  is 
essayed  by  the  administration  of  naphthalene  and  salol.  each  gr.  x-xx  three 
times  a  day,  and,  when  stricture  does  not  prevent  it,  high  enemata  of  boric- 
acid  solution  are  given  twice  daily.  The  parts  are  thoroughly  shaved,  all  external 
antiseptic  precautions  taken,  and,  after  the  patient  is  anesthetized,  the  rectum  is 
thoroughly  irrigated  with  1-5000  bichloride  solution.  When  an  artificial  anus  has 
been  established  l}y  colostotomy  prior  to  the  operation,  it  will  only  be  necessary  to 
give  a  purgative  the  day  before  the  operation,  and  salol  and  naphthalene  need  not 
be  given.     Irrigation  with  Ijoric-acid  solution  is,  however,  indicated. 

The  conditions  are  extremely  rare  when  the  method  of  Ivraske  or  any  modifi- 
cation of  the  operation  which  requires  an  osteoplastic  section  of  the  sacrum  will 
be  required.  When  the  upper  margin  of  the  growth  can  be  reached  by  the  tip  of 
the  index-finger,  Tuttle's  modification  of  Quenu's  operation  will  meet  all  the  indi- 
cations. When  the  disease  extends  beyond  this  limit,  that  method  comljined  with 
the  Mayo  technic  from  above  will  be  necessary. 

The  patient  is  placed  in  the  comljined  Trendelenburg  and  lithotomy  position. 
The  rectum  is  thoroughly  irrigated  with  normal  salt  solution,  dried  out,  and 
loosely  packed  with  gauze  in  order  that  one  ma}'  recognize  a  close  approach  to  its 
walls  during  the  dissection.  A  circular  incision  is  made  through  the  skin  around 
the  anus,  and  this  with  the  rim  of  the  bowel  is  dissected  up  inside  of  the  external 
sphincter  for  one  half  inch.  A  strong  silk  suture,  the  ends  of  which  are  left  long 
for  purposes  of  traction,  is  tied  around,  completely  closing  the  freed  end  of  the 
rectum.  The  mucous  lining  and  margins  of  the  anus  below  the  ligature  are  now 
cauterized  with   the  Paquelin  blade,   to   destroy   any  infectious  organisms.     The 


488  RECTUM   AND   ANUS 

external  sphincter  is  incised  anteriorly  and  posteriorly  entirely  outside  of  the  rec- 
tum, the  posterior  incision  being  carried  back  to  the  tip  of  the  coccyx  and  well 
into  the  retrorectal  space.  The  rectum  is  then  dissected  from  its  attachments 
laterally  and  posteriorly,  the  sphincter,  if  not  involved  in  the  growth,  being  left 
in  the  slvin-flaps.  In  doing  this,  the  levator  ani  muscle  should  be  cut  off  as  close 
to  the  rectum  as  possible  ( Fig.  S07a) .  The  skin  and  sphincter  muscle  having  been 
incised  in  the  anterior  line  as  far  as  the  junction  with  the  scrotum,  the  rectum 
is  drawn  backward  and  dissected  loose  anteriorly  up  to  the  level  of  the  levator  ani, 
which  is  much  higher  here  than  posteriorly.  The  finger  is  then  introduced  from 
behind  forward  above  the  anterior  fibers  of  the  levator  and  the  deep  perineal  fascia, 
and  by  gently  dragging  downward,  these  are  separated  from  the  rectum  in  the 
lines  of  cleavage.  When  this  has  been  accomplished  on  both  sides,  the  anterior 
attachment  of  the  levator  and  ano-bulbar  raphe  to  the  rectum  are  cut  through 
upon  the  linger,  and  the  organ  is  thus  freed  in  its  entire  circumference.  The 
rectum  is  now  easily  separated  by  the  finger  in  the  superior  pelvi-rectal  space  until 
the  peritoneal  cul-de-sac  is  reached  in  front  (Fig.  507&).    At  this  point  the  lateral 


Fig.  507a. — Extirpation  of  the  anus  and  rectum  by  the  perineal  approach.  The  dissection  has  been 
carried  up  within  the  external  spliincter,  which  is  widely  retracted.  Tlie  levator  ani  muscle  has  beea 
divided  near  its  inclusion  of  R,  the  bowel-wall.     L,  Levator  ani.     M,  Median  raphe.     (After  Tuttle.) 

connective-tissue  folds  which  support  the  rectum  on  the  sides  must  be  clipped  with 
scissors,  after  which  the  gut  may  be  dragged  well  outside  of  the  wound.  While 
the  peritonaeum  can  at  times  be  stripped  from  the  rectum,  it  is  better  when  the 
growth  extends  well  up  to  open  the  cavity  at  once.  Before  doing  this  it  is  advisable 
to  disarticulate  the  coccyx  and  fold  it  backward,  in  order  to  obtain  more  room, 
and  to  separate  the  rectum  from  the  sacrum  by  breaking  up  the  attachments  with 
the  finger.  The  peritonasum  on  the  anterior  surface  of  the  rectum  is  then  incised, 
cut  loose  from  its  attachments  close  to  the  rectum  back  to  the  meso-rectum,  which 
latter  should  be  divided  close  to  the  sacrum  in  order  to  avoid  wounding  the  inferior 
mesenteric  artery.  When  the  gut  has  been  loosened  sufficientl}^  aljove  the  tumor 
to  be  brought  do'mi  and  sutured  to  the  anus,  the  surgeon  should  close  the  peri- 
tonaeum and  restore  the  planes  of  the  pelvic  floor  down  to  the  levator  ani  with 
fine  chromieized  catgut  sutures.  This  accomplished,  the  anus,  which  is  now  well 
outside  of  the  operative  field,  should  be  reopened,  the  gauze  packing  in  the  rectum 
removed,  and  the  gut  flushed  with  a  solution  of  mercuric  chloride,  1-3000.     It  is 


RECTUM   AND   ANUS 


489 


then  amputated  through  the  healthy  tissue  well  above  the  tumor,  and  its  upper 
end  sutured  at  the  original  site  of  the  anus.     Quenu  advises  that,  in  amputating, 


Fig.  5076. — Showing  the  deeper  dissection.      L,  Levator 
seminal  vesicles;  P,  prostate. 


ni;   G,  neoplasm;    P,  peritoneal  pouch;  S, 
(After  Tuttle.) 


each  layer  should  be  cut  separately  in  order  to  avoid  hasmorrhage.  Tuttle  holds 
that  there  is  no  advantage  in  this,  "  in  fact,  we  are  much  more  likely  to  meet  with 
a  rather  deficient  blood  supply  causing  subsequent  sloughing  of  the  gut  than  with 


Fig.  S07c. — The  operation  completed,  showing  the  gauze  packing  and  drains  above  and  below,  and  at  U 
the. rectal  tube.     (After  Tuttle.) 


490 


RECTUM   AND  ANUS 


liEemorrhage."  The  posterior  and  anterior  portions  of  tlie  wound  are  packed  with 
gauze,  and  left  open  to  insure  drainage  (Fig.  50Tc),  and  the  parts  are  covered  with 
aseptic  pads  held  into  position  by  a  well-fitting  napkin  or  broad  T-bandage.  A 
large  drainage-tube  is  passed  well  up  into  the  rectum,  its  lower  end  extending 
outside  of  the  dressings  in  order  to  convey  the  discharges  and  gases  beyond  the 
operative  wound/ 

In  cancer  of  the  reetunr  in  women,  the  vaginal  route  is  advised.  The  technic 
of  the  operation  as  given  by  Murphy  is  as  follows:  The  position  is  the  same  as 
just  given.  The  vagina  is  dilated  with  broad  retractors,  the  cervix  drawn  down, 
and  Douglas'  ciil-de-sac  opened  by  a  transverse  incision  just  below  the  cervical 
juncture.  The  small  intestines  are  pushed  upward  and  the  peritoneal  cavity  packed 
with  large  laparotomy  sponges  or  pads,  a  careful  count  of  which  should  be  noted. 
The  recto-vaginal  septum  is  then  divided  by  a  vertical  incision  in  the  median  line, 
extending  from  the  first  incision  down  to  the  margin  of  the  anus  and  including 
the  external  sphincter  (Pig.  507d).  The  vaginal  wall  is  dissected  from  its  attach- 
ments to  the  rectum,  exposing  this  organ  in  its  entire  length,  enabling  one  to  exam- 


FiG.  507d. — The  cervix  drawn  upward  and  outward,  the  cul-de-sac  opened,  and  the  long  incision  in  the 
posterior  ^•aginal  wall  outlined.      (After  J.  B.  Murphy  and  Tattle.) 


ine  it  and  drag  doT\-n  the  sigmoid  flexure  at  will  (Fig.  50Tp).  The  anterior  rectal 
wall  is  now  divided  to  the  lower  border  of  the  tumor,  and  the  gut  incised  trans- 
versely one  inch  l)elow  the  lower  limits  of  the  growth,  carrying  the  incision  into 
the  retrorectal  tissue.  The  proximal  end  of  the  gut  is  grasped  with  forceps  which 
close  it,  and  hj  the  use  of  the  curved  scissors  it  is  separated  from  its  posterior 

'  The  foregoing  technic  is  credited  to  Tuttle's  "  Diseases  of  the  Anus,  Rectum,  and  Pelvic 
Colon." 


RECTUM   AND   ANUS  491 

attachments  as  far  as  the  ijromoiitorj'  of  the  sacrum,  or  siiffieiently  far  to  allow 
the  howel  to  be  drawn  down  and  out  until  its  healthy  portion  reaches  the  lower 
segment  without  undue  tension.  The  gut  is  then  amputated  above  the  growth 
(Fig.  507/),  and  the  upper  and  lower  segments  are  united,  end  to  end,  by  silkworm 
sutures.    These  sutures  should  be  passed  so  as  to  permit  the  knots  being  tied  upon 


Fig.  507f. — The  posterior  vaginal  wall  lifted  from  the  rectum.     (After  Murphy  and  Tuttle.) 

the  inside,  and  the  ends  left  long  to  facilitate  their  removal.  The  anterior  wound 
of  the  rectum  is  closed  in  a  similar  manner,  and  the  ends  of  the  sphincter  are 
brought  together  by  buried  catgut  siitures  (Fig.  507 g).  After  the  laparotomy 
pads  are  removed,  the  peritoneal  wound  is  closed  with  a  continuous  catgut  suture, 
and  the  vaginal  wound  is  l^rought  together  with  silkworm-gut  stitches.  A  large 
drainage-tube  is  introduced  through  the  anus  above  the  j^oint  of  anastomosis  and  su- 
tured in  position,  the  vagina  and  external  parts  being  dressed  with  sterilized  gauze. 

Tuttle  has  modified  the  above  technic  of  ]\Iurphy  by  commencing  the  operation 
with  a  semicircular  incision  between  the  anus  and  coccyx,  and  extending  this  into 
the  retrorectal  space.  With  the  fingers  or  a  dull  instrument  the  cellular  tissues 
and  rectum  are  separated  from  the  anterior  surface  of  the  sacrum  and  the  coccyx 
as  high  up  as  the  growth  extends.  After  this  has  been  accomplished  the  wound 
and  sacral  concavity  are  packed  with  sterile  gauze,  to  control  the  oozing,  and  the 
vaginal  portion  of  the  operation  is  then  carried  out  as  directed  by  Murphy,  witli 
the  exception  that  the  gut  is  not  cut  across  until  it  has  been  freed  from  all  its 
attachments,  dragged  down  as  far  as  is  necessary,  and  the  peritoneal  cavity  closed 
by  sutures  or  firm  i^acking. 

Polypus. — Three  distinct  forms  of  polypi  are  found  in  the  rectum,  namely — the 
villous,  mncoiis,  and  fibrous. 


492 


RECTUM   AND   ANUS 


The  first  of  these  is  the  most  important,  for,  while  essentially  benign  in  the 
earlier  stages  of  its  development,  it  maj^,  as  a  result  of  the  irritation  to  which  it  is 
subjected,  become  malignant.  It  is  composed  of  newly  formed  villi,  which  resemble 
the  normal  villi  of  the  rectum.  They  are  very  vascular,  and  difEer  from  the  mucous 
or  filjrous  polypus  not  only  in  their  minute  structure,  but  in  gross  appearances  and 
the  character  of  their  attachment  to  the  mucous  membrane.  AVhile  these  latter 
are  pedunculated,  often  hanging  by  a  narrow  stem,  the  villous  growth  'has  a  broad 
attachment  frequently  as  thick  as  the  tumor  is  long. 

The  mucous  or  soft,  and  the  fibrous  or  hard,  polypus  of  the  rectum  does  not 
difEer  in  any  essential  particular  from  that  already  described  in  affections  of  the 
nasal  cavities.  In  some  instances  the  deeper  portions  of  the  tumor  undergo  cystic 
degeneration,  forming  the  so-called  cystic  polypus. 

Polypi  of  the  rectum  may  occur  at  any  period  of  life,  being  comparatively  fre- 
quent in  childhood.  The  most  common  location  of  these  tumors  is  on  the  posterior 
wall  of  the  bowel,  just  above  the  internal  sphincter.     The  pedunculated  variety  in 


Fig.  507/. — Excision  of  the  diseased  segment.     (After  Murpliy  and  Tuttle.) 


some  instances  protrude  through  the  anus,  causing  violent  tenesmus.  When  not 
removed  these  neoplasms  may  brealv  down,  causing  nicer  or  fissure  of  the  bowels, 
severe  hsemorrhage,  or  by  their  weight  cause  prolapse  of  the  mucous  membrane. 

The  diagnosis  is  readily  made  by  inspection  or  digital  exploration,  after  the 
rectimi  is  thoroughly  cleansed  by  an  enema.  The  treatment  consists  in  removal 
of  the  tumor  by  the  forceps,  scissors,  or  ligature. 

Villous  papilloma,  or  "  villous  tumor,"  according  to  Mathews,  is  the  rarest 
form  of  rectal  neoplasm.  "  It  is  likely  to  be  mistaken  for  polypus  because  it  is 
pedunculated.    In  polypus  the  stem  is  round,  in  villous  tumor  broad."    The  clinical 


RECTUM   .IXD   AXUS 


493 


feature  of  most  importance  is  the  frequent  lijemorrhage  ■which  occurs  from  rectal 
papilloma,  caused  by  the  passage  of  ingested  matter.  The  treatment  consists  in 
the  removal  of  the  mass  after  a  ligature  has  been  thro-nn  aroimd  it  close  to  the 
pedicle.  It  is  a  wise  precaution  after  removal  to  thoroughly  touch  the  base  of  the 
tumor  with  the  Paquelin  cautery.  There  is  very  little  danger  of  haemorrhage  in 
such  treatment. 

Neuralgia. — Pain,  neuralgic  in  character,  is  occasionally  felt  in  the  rectum  or 
about  the  anus.    In  some  instances  it  is  caused  by  displacement  of  the  coccyx,  the 


Fig.  5073. — Reuiiiu 


,.^t.r  M:^i_.i 


unterior  longitudinal 


bone  in  the  abnormal  position  pressiag  iipon  the  fifth  sacral  or  coccygeal  nerve, 
or  directly  against  the  wall  of  the  bowel.  The  diagnosis  is  readily  made  out  by 
direct  examination.     The  only  means  of  cure  is  by  removal  of  the  displaced  bone. 

The  operation  is  performed  as  follows:  The  patient  is  placed  upon  the  side  and 
an  incision  is  made  in  the  median  line,  from  the  tip  of  the  coccyx  to  about  one 
inch  above  the  sacro-coccygeal  articulation.  The  tissues  are  first  lifted  directly 
from  the  dorsal  aspect  of  the  bone,  and  then  the  anterior  surface  is  exposed  by 
beginning  at  the  tip  and  keeping  close  to  the  smooth  face  of  the  eoccvx:.  There  is 
no  danger  of  wounding  the  bowel  if  this  precaution  is  taken.  When  the  dissection 
is  completed,  the  bone  shotdd  be  divided  at  the  sacro-coccygeal  junetion  with  the 
cutting  forceps  or  chisel. 

Idiopathic  neuralgia  of  the  rectum  and  anus  may  occur  as  in  other  portions 
of  the  body.     Spasm  of  the  sphincter  is  occasionally  due  to  this  cause. 

Prolapsus  Eecii. — Protrusion  of  the  rectum  may  be  complete  or  incomplete. 
In  the  incomplete  variety  the  lining  membrane  of  the  bowel  is  alone  protruded. 
The  everted  portion  may  include  a  narrow  ring  of  the  mucous  membrane  near  the 


494  RECTUM   AND   ANUS 

anus,  or  it  may  measure  an  inch  or  more  in  width.  In  the  complete  prolapsus 
more  or  less  of  the  entire  thickness  of  the  wall  of  the  .rectum  is  dragged  downward 
and  everted.  The  process  commences  usually  near  the  anus,  and  in  the  complete 
form  the  fascia  which  attaches  the  rectum  to  the  promontory  of  the  sacrum  is 
elongated,  and  the  peritonisum  dragged  down  toward  the  anal  aperture.  In  the 
pocket  thus  formed  a  loop  of  intestine  may  descend  and  become  strangulated. 

Prolapsus  recti  may  occur  at  any  period  of  life,  although  usually  met  with  in 
children.  In  a  varying  degree  it  exists  as  a  complication  in  all  cases  of  chronic 
hemorrhoids.  It  is'frequently  caused  by  frequent  and  prolonged  straining  at  stool. 
A  predisposing  cause  in  adults  is  habitual  constipation,  with  the  overdistention 
of  the  bowel  which  is  the  result  of  this  condition.  In  children,  it  is  thought  that 
the  peculiar  shape  of  the  sacrum,  tlie  curve  of  which  is  much  less  pronounced  than 
in  adults,  renders  this  class  of  patients  more  liable  to  prolapsus.  It  is  probable 
that  indiscretions  in  diet,  the  lack  of  restraint,  and  the  low,  squatting  posture  too 
often  permitted  in  children  in  the  act  of  defecation,  are  more  responsible  for  this 
accident  than  the  straight  position  of  the  bowel. 

Diseases  of  the  bladder  and  prostate,  uterus  and  ovaries,  pregnancy,  or  the 
presence  of  a  tumor,  are  also  to  be  considered  as  exciting  causes  of  this  lesion. 
Finally,  the  weak  and  infirm  are  more  lialile  to  Ije  affected  than  the  robust. 

When  prolapsus  occurs  it  is  accompanied  with  a  sense  of  distention,  heaviness, 
and  dragging  down,  which  causes  great  pain  and  anxiety  to  the  patient.  In  recent 
cases  in"  which  there  is  only  an  eversion  of  the  mucous  membrane,  this  will  be 
seen  projecting  beyond  the  limit  of  tlie  anus  on  one  or  both  sides,  or  in  severer 
cases  including  its  entire  circumference.  The  prolapsed  fold  or  ring  is  of  a  reddish- 
purple  color,  varying  with  the  degree  of  strangulation,  and  is  broken  at  intervals 
by  furrows  or  depressions  which,  in  the  main,  seem  to  radiate  from  the  center 
of,  the  protrusion.  When  complicated  with  hemorrhoids,  these  will  be  easily 
recognized  by  their  shape  and  color,  giving  a  swollen  and  nodulated  appearance, 
which  could  not  exist  in  simple  eversion.  In  differentiating  partial  from  complete 
prolapsus,  the  chief  points  are  the  thinness  of  the  prolapsed  ring  in  the  partial 
form,  and  the  radiating  direction  of  the  furrows.  In  complete  prolapse  the  mass 
is  markedly  thicker,  more  strangulated,  and  tlie  folds  of  mucous  membrane  are 
more  nearly  circular  in  arrangement. 

Treatment. — In  acute  prolapsus  the  immediate  indication  is  to  relieve  the 
strangulation  and  restore  the  prolapsed  portion  to  its  normal  position.  The  re- 
moval of  the  cause  or  causes  of  the  accident  is  next  in  importance.  The  first 
indication  is  met  by  placing  the  patient  upon  the  left  side,  with  the  pelvis  well 
elevated,  the  shoulders  and  head  depressed,  or  in  the  knee-shoulder  position,  in 
either  of  which  the  return  of  the  bowel  is  aided  by  gravity.  The  fingers  of  the 
operator  and  the  protruded  mass  should  now  be  well  lubricated,  and  steady  and 
gentle  pressure  exercised  upon  the  tumor  in  the  direction  of  the  normal  position 
of  the  bowel.  In  almost  all  cases  this  practice  will  succeed.  When,  on  account  of 
spasm  of  the  sphincter,  the  strangulation  is  so  great  that  gangrene  is  threatened 
and  reduction  impossible,  an  anesthetic  should  be  administered  and  forcible  dila- 
tation efl:ected  by  the  thumbs  of  the  operator,  after  which  the  mass  will  readily 
return-  within  the  anus.  Once  reduced,  the  greatest  pains  must  be  observed  to 
prevent  the  repetition  of  the  accident.  Fecal  accumulation  and  straining  should 
be  prevented  by  the  injection  of  cold  water  when  there  is  a  need  or  desire  for  an 
evacuation,  and  by  the  use  of  the  bedpan.  In  children  it  is  essential  that  they 
should  not  be  allowed  to  squat  upon  a  low  vessel,  or  place  themselves  in  a  con- 
strained position  at  stool.  The  position  assumed  should  be  one  where  gravitation 
will  not  carry  the  intestines  toward  the  anus.  Lying  upon  the  side,  with  the 
buttocks  slightly  projecting  over  the  edge  of  the  bed  or  table,  or  defecating  in 
the  knee-elbow  position,  should  be  insisted  upon.  Any  condition  which  con- 
tributes to  the  cause  of  prolapse  must  be  removed  or  palliated.  When,  despite 
all  conservative  methods,  the  prolapse  becomes  chronic,  growing  progressively  worse, 
operative  interference  becomes  imperative.  The  preparation  of  the  patient  is  the 
same  as  for  other  operations  about  the  rectum.  After  the  narcosis  is  complete, 
the  patient  is  placed  in  the  lithotomy  position,  with  the  pelvis  elevated  to  such  an 


RECTUM   AXD   ANUS  495 

extent  that  the  intestines  will  gravitate  toward  the  diaphragm,  the  mass  returned,, 
and  a  large  sponge  introduced  well  up  into  the  bowel.  The  sphincter  ani  and 
rectum  should  now  be  widely  dilated  with  the  speculum  until  the  walls  of  the 
bowel  are  brought  clearly  into  view.  The  Pac[uelin  cautery  knife,  heated  to  a 
light-red  color,  is  carried  into  the  bowel  as  high  as  the  limit  of  the  prolapsed  por- 
tion, and  drawn  straight  down  the  wall  of  the  gut  to  the  margins  of  the  anus, 
burning  its  way  through  the  mucous  membrane.  The  depth  of  the  furrow  must 
be  determined  by  the  extent  of  the  prolapse.  If  the  entire  thickness  of  the  rectal 
wall  is  involved,  as  in  complete  prolapsus,  the  wound  should  extend  well  into  the 
muscular  layer.  In  partial  prolapse  it  will  suffice  to  go  down  to  the  muscle.  From 
four  to  six  incisions  should  be  made  at  equal  distances  from  each  other.  Partial 
divulsion  of  the  sphincter  should  be  made  before  or  after  the  operation,  in  order 
to  prevent  spasm  and  to  secure  rest.  A  complete  recovery  will  follow  in  the  large 
majority  of  cases.  If  the  Paquelin  cautery  cannot  be  obtained,  strong  iron  wire, 
or  rod  iron,  may  be  used  bj'  heating  in  the  ordinary  furnace.  The  after-treatment 
is  to  keep  the  patient  quiet  with  mild  opium  narcosis,  and  after  five  or  six  days 
to  move  the  bowels  with  a  cold-water  enema,  keeping  the  patient  in  the  recumbent 
posture.  The  cure  is  effected  hj  the  formation  of  inflammatory  adhesions  between 
the  mucous  membrane  and  muscle,  and  between  the  outer  •\\'all  of  the  rectum  and 
the  perirectal  connective  tissues  and  fascite.  The  older  operation  of  excising 
a  V-shaped  piece  of  the  mucous  membrane  and  afterward  uniting  the  edges  by 
sutures,  is  bloody  and  troublesome,  and  not  to  be  comjiared  to  the  procedure  above 
given. 

In  chronic  prolapse,  the  most  satisfactory  procedure  is  the  operation  of  White- 
head, carried  out  as  if  it  w'ere  being  done  for  haemorrhoids  instead  of  prolapse.  It 
is  well  to  bear  in  mind,  as  emphasized  in  the  description  of  this  operation  for 
hsemorrhoids,  the  danger  of  cutting  away  too  much  of  the  mucous  membrane. 
Whitehead's  operation  is  better  adapted  to  chronic  prolapse  than  any  other  pro- 
cedure. 

In  very  exceptional  instances  celiotomy  is  indicated,  with  suture  of  the  bowel 
to  the  pelvic  fascia  after  the  prolapse  has  been  reduced.  The  lumen  of  the  over- 
dilated  lower  segment  may  also  be  narrowed  by  plication  from  the  peritoneal  side. 
Chromicized  catgut  sutures  should  be  employed.  In  all  essentials  the  procedure  is 
the  same  as  gastroplication. 

HiElIOEEHOIDS 

Hajmorrhoids,  or  "piles,"  are  vascular  tumors  or  varicosities  formed  beneath 
the  mucous  membrane  of  the  rectum  and  anus.  They  are  divided  anatomically 
into  external  and  internal  haemorrhoids.  Internal  hsemorrhoids  are  again  divided 
into  venous,  arterio-venous,  and  capWarij  haemorrhoids. 

The  veins  which  are  involved  in  hajmorrhoids  belong  to  two  plexuses,  between 
which,  ordinarily,  there  is  not  a  free  anastomosis.  The  inferior  or  external  haem- 
orrhoidal  plexus  is  situated  in  the  last  portion  of  the  rectrim,  within  about  one 
inch  of  the  anus,  and  the  blood  from  this  part  returns  by  way  of  the  middle  and 
inferior  hEemorrhoidal  veins  to  the  iliacs,  and  thence  by  the  inferior  cava  to  the 
heart.  The  superior  or  internal  plexus  occupies  the  rectum  above  this  point,  and 
from  this  portion  the  blood  returns  by  the  portal  system,  passing  through  the  liver. 

In  their  incipiency,  external  hccmorrhoids  are  simple  varicosities  of  the  inferior 
plexus.  Later,  as  a  result  of  engorgement  and  repeated  inflammation,  the  walls 
become  thickened  from  the  presence  of  newly  formed  connective  tissue,  which,  in 
the  process  of  contraction  peculiar  to  this  product  of  inflammation,  often  causes 
obliteration  of  the  vein  within  the  tumor.  The  remains  of  these  tumors  are  seen 
in  almost  all  cases  of  chronic  external  haemorrhoids,  where  they  appear  as  tags 
of  thickened  skin  of  variable  size  and  shape,  collected  around  the  margin  of 
the  anus. 

Internal  liwmorrhoids  of  recent  development  are  also  varicosities  of  the  inter- 
nal or  portal  plexus,  but  when  of  long  duration  the  tumors  very  frequently  contain 
arterioles  of  considerable  size.  The  mucous  membrane  of  the  deeper  portions  of 
the  rectum  is  at  times  studded  with  small,  raspberry-like  elevations,  which  bleed 


496  RETCUM   AND   ANUS 

profusely,  are  found  to  contain  a  rich  network  of  capillaries,  and  for  this  reason 
are  termed  capillary  liwmorrhoids. 

External  HcBmorrhoids — Acute  and  Chronic. — This  form  of  tumor,  commonly 
known  as  "  dry  piles,"  is  of  frequent  occurrence.  Few  individuals  live  beyond 
the  age  of  forty  without  being  affected.  The  chief  cause  is  habitual  constipation 
and  the  overdistention  of  the  lower  portion  of  the  rectum  in  the  act  of  defecation. 
Prolonged  straining  at  stool,  even  without  the  discharge  of  fecal  matter,  will  alsq 
aid  in  the  development  of  piles.  Gravitation  by  reason  of  the  erect  posture  is  also 
entitled  to  a  consideration  in  the  aetiology  of  haemorrhoids,  since  man  is  the  only 
animal  thus  affected.  Pressure  upon  the  iliac  veins  or  the  inferior  cava  by  the 
gravid  uterus,  or  any  form  of  tumor,  will  also  aid  in  producing  varicosities  of  the 
hsemorrhoidal  veins  as  well  as  in  those  of  the  lower  extremities. 

A  patient  who  is  suffering  from  an  acute  external  haemorrhoidal  tumor  will 
usually  give  a  history  of  constipation  and  straining  at  stool,  with  an  unnatural 
sense  of  fullness  and  heaviness  about  the  anus,  and  of  considerable  pain  while  the 
evacuation  is  taking  place,  for  several  days  before  the  protrusion  is  noticed.  Imme- 
diately after  an  evacuation  a  swelling  is  noticed  just  outside  of  the  anus  which  is 
painful  to  the  touch,  and  which  cannot  be  pushed  into  the  bowel.  Upon  inspection, 
a  recent  external  hjemorrhoidal  tumor  usually  appears  tense  and  glistening  on  the 
surface,  and  red  or  reddish-blue  in  color.  It  is  partly  within  and  partly  outside 
of  the  anus.  There  may  be  a  single  swelling,  which  is  spherical  in  shape,  or  it 
may  be  crescentic,  occupying  half  of  the  anal  margin.  If  not  observed  until  after 
several  days  have  elapsed,  and  ■\\-hen  the  tension  or  partial  strangulation  has  not 
been  relieved,  ulceration  may  have  occurred,  with  inflammation  and  induration  of 
the  tissries  near  the  base  of  the  tumor.  In  other  instances  which  do  not  come 
under  the  observation  of  a  physician,  the  patient  goes  to  bed,  pushes  the  tumor 
within  the  anus,  the  symptoms  disappear  within  a  day  or  two,  to  recur  again  and 
again  under  the  same  conditions. 

Chronic  external  hemorrhoids  differ  from  the  acute  form  just  described  in  the 
following  particulars :  Thej  are  brown  or  bluish  in  color,  are  not  tense  or  painful, 
are  loose  and  flabby,  and  have  a  thickened,  leathery  feel  when  pinched  between 
the  fingers. 

Treatment. — This  may  be  palliative  or  curative.  Tension  in  the  tumors  may 
be  lessened  by  placing  the  patient  in  the  Ivuee-shoulder  position  and  making  gentle 
pressure  upon  tlie  mass  until  it  slips  within  the  anus.  The  cure  of  acute  external 
liEemorrhoids,  however,  is  so  simple  that  it  is  rarely  advisable  to  delay  operation. 
There  are  rarely  more  than  two  or  three  of  these  masses,  and  by  injecting  directly 
into  each  one  two  to  five  minims  of  a  one-per-eent  cocaine,  or  two  per  cent  quinia 
and  urea,  solution,  all  sensation  is  lost  as  the  tumor  is  incised  with  a  sharp-pointed 
curved  bistoury,  carried  through  its  base,  splitting  it  and  turning  out  the  clot,  and 
inserting  a  little  film  of  boric  cotton  or  sterile  gauze  to  arrest  bleeding.  The 
wound  heals  in  the  course  of  a  week,  and  the  liEemorrhoids  do  not  recur.  Should 
the  patient  be  unusually  apprehensive  or  the  anal  region  more  than  ordinarily 
sensitive,  ether  spray  by  means  of  the  Richardson  atomizer  will  deaden  sensibility 
to  the  needle  puncture  and  the  infiltration.  In  the  case  of  chronic  external  haemor- 
rhoids with  prolapsus  ani,  the  operation  of  AVhitehead  is  indicated.  Old  withered- 
up  external  hsemorrhoids  may  be  easily  removed  by  grasping  the  tumor  with  a  pair 
of  mouse-tooth  forceps,  and  cutting  it  off  with  scissors.  Local  anaesthesia  may 
be  employed  if  deemed  necessary. 

Internal  Hmmorrhoids, — Constipation,  overdistention  of  the  rectu,m,  and  pro- 
longed straining  at  stool  must  also  be  considered  as  among  the  principal  causes 
of  internal  piles.  In  addition  to  these,  any  disease  of  the  liver  which  causes  a 
retardation  of  the  return  of  blood  through  the  portal  circulation  will  aid  in  pro- 
ducing internal  liEemorrhoids. 

Pressure  upon  the  portal  vein,  or  upon  the  inferior  mesenteric  vein,  whether 
due  to  an  overloaded  condition  of  the  alimentary  canal  or  a  tiamor,  will  produce 
the  same  effect. 

Symptoms. — Internal  piles,  as  a  rule,  cause  little  or  no  pain  or  annoyance  until 
they  are  sufficiently  developed  to  be  caught  in  the  grip  of  the  sphincter,  or  are 


RECTOI   AXD   AXrS  497 

protruded  through  the  anus.  Previous  to  their  descent,  however,  a  variable  amount 
of  bleeding  has  usually  occurred,  often  enough  to  attract  the  attention  and  excite 
the  alarm  of  the  patient.  This  is  especially  ti'ue  of  the  arterio-venous  and  capillary 
tumor,  although  the  venous  tumor  not  infrequently  gives  rise  to  considerable 
haemorrhage. 

Tpon  digital  examination  the  presence  of  the  haemorrhoids  may  be  easily  recog- 
nized, and  ocular  demonstration  may  be  made  by  the  careful  dilatation  of  the 
sphincter  with  the  Sims  rectal  specttfum.  If  a  free  enema  of  warm  water  be  ad- 
ministered, the  tumors  will  usually  protrude  with  the  discharge  of  the  water  if 
the  patient  is  placed  in  the  squatting  posture,  and  is  directed  to  make  a  strong 
expulsive  eifort. 

'Treatment. — The  preliminary  treatment  should  be  instituted  seventy-two  hours 
before  any  operative  procedure  for  internal  haemorrhoids.  A  full  dose  of  castor  oil 
(two  ounces)  in  sarsaparilla  should  be  given  at  bedtime,  and  in  the  case  of  aii 
ordinary  individual  this  procedure  should  be  repeated  forty-eight  hours  before 
the  operation.  Twelve  hours  before  the  anaesthetic  is  administered,  the  patient 
should  receive  a  full  irrigation  of  the  colon  with  hot  normal  salt  solution.  After 
this  nothing  should  be  done  until  the  patient  is  unconscious  and  on  the  table.  The 
subject  should  be  in  the  lithotomy  position,  and  when  help  is  scarce  the  legs 
should  be  held  by  the  Clover  crutch.  The  operator  should  wear  rubber  gloves,  and 
every  precaution  taken  to  prevent  accidental  soiling  should  the  patient  vomit  or 
struggle.  The  internal  and  external  sphincter  ani  muscles  should  be  slowly  and 
carefullv  stretched  by  an  instrument,  or  preferably  with  the  lubricated  fingers  of 
the  two"  hands.  The'  dilatation  should  be  in  all  directions  and  so  gradual  that  no 
muscular  fibers  are  ruplTired,  and,  if  possible,  the  mucous  membrane  not  torn.  A 
rubber  bulb  (Barnes'  dilator)  should  now  be  introduced  several  inches  up  the 
bowel  and  filled  with  water.  This  prevents  the  descent  of  soiling  material,  and  by 
pressure  on  the  veins  causes  a  temporary  distention  of  the  hfemorrhoids.  If  the 
rubber  bulb  is  not  at  hand,  a  sponge  of  the  proper  size  or  a  plug  made  of  absorbent 
gauze,  to  which  a  strong  cord  has  been  attached,  is  carried  well  up  into  the  bowel 
along  the  trough  of  a  large  Sims  speculum. 

All  that  part  of  the  bowel  below  the  plug  and  the  entire  anal  region  should 
be  cleansed  with  soap  and  water  and  1-5000  sublimate  solution.  The  operator 
l3v  introducing  one  or  two  fingers  and  by  pressure  from  above  downward  will  cause 
the  mucous  memljrane  to  prolapse  and  bring  the  hemorrhoidal  tumors  well  down 
to  the  margin  of  the  anus.  If  varicosities  are  present  in  the  entire  rectal  and  anal 
circumference,  and  if,  as  is  almost  always  the  case  with  chronic  haemorrhoids,  there 
is  a  prolapse  of  the  mucous  membrane,  the  ideal  operation  is  complete  excision  of 
all  the  haemorrhoidal  varicosities,  together  with  a  section  of  the  mucous  membrane 
of  the  rectum  (Whitehead's  operation). 

By  the  use  of  scissors  and  dissecting  forceps  the  mucous  membrane  is  divided 
at  its  junction  with  the  skin  throughout  the  entire  circumference  of  the  bowel, 
every  irregularity  of  the  muco-cutaneous  junction  being  carefully  followed.  By 
commencing  this  incision  at  the  most  dependent  portion  of  the  anal  circumference 
and  proceeding  upward,  the  line  is  not  obscured  by  the  bleeding  which  occurs.  The 
assistant,  who  uses  the  irrigator  with  hot  salt  solution,  should,  from  time  to  time, 
flush  (not  splatter)  the  wound  in  order  to  clear  the  field  and  retard  bleeding. 
The  external  sphincter  muscle,  the  circular  arrangement  of  the  fibers  of  which 
may  readily  be  recognized  if  the  wound  be  kept  dry,  should  be  carefully  sought 
and  the  operator  should  keep  to  the  inner  or  mucous  side  of  this  muscle.  The 
forceps  should  be  applied  freely,  and  all  bleeding  points  tied  at  once  with  very 
fine  catgut.  After  the  external  sphincter  muscle  has  been  exposed,  the  dissection 
may  be  rapidly  made  with  the  dull-pointed  scissors  and  with  slight  bleeding.  It 
will  usually  stifBce  to  remove  a  strip  of  the  mucous  lining  membrane  not  more 
than  one  half  to  three  quarters  of  an  inch  in  width.  Great  care  should  be  taken 
not  to  remove  too  much  for  fear  the  sutures  may  tear  loose  from  too  great  tension 
and  a  cicatricial  ring  or  band  be  formed,  causing  post-operative  contraction.  A 
Xo.  2  ten-day  catgut"  sutttre  is  now  introduced  through  the  skin  about  one  eighth 
of  an  inch  from  the  edge  of  the  incision.     Avoiding  the  sphincter  muscle,  the 


498 


RECTUM   AND   ANUS 


needle  enters  the  mucous  membrane  passing  one  fourth  of  an  inch  beyond  the 
point  where  it  is  to  be  divided.  The  mucous  membrane  is  split  directly  down 
to  one  fourth  of  an  inch  from  the  point  where  it  was  penetrated  by  the  needle, 
and  this  suture  is  immediately  tied  in  such  a  way  that  the  edge  of  the  mucous 
membrane  and  the  edge  of  the  skin  are  in  apposition.  Half  an  inch  beyond  a 
second  suture  is  inserted,  and  the  mucous  membrane  is  then  divided  transversely 
as  far  as  this  second  suture,  which  is  also  to  be  tied. 

This  operation  is  repeated  for  the  entire  circumference  of  the  bowel,  tying 
each  suture  as  it  is  inserted  after  the  mucous  membrane  has. been  divided.  Half- 
way between  the  iirst  row  of  sutures  a  second  row  should  now  be  inserted,  and 
at  any  points  where  the  apposition  is  not  entirely  satisfactory  small  intermediate 
sutures  of  plain  catgut  may  be  used.  It  is  important  that  the  sutures  should  be 
so   closely   applied   that    the   mucous   membrane   and   the   skin   are   absolutely   in 


Fig.  508. — Pilcher's  operation  for  haemorrhoids, 
sliowing  a  single  pile  clamped  with  a  long 
slightly  curved  forceps  and  a  curved  needle 
carrying  a  chromicized  catgut  suture  passed 
beneath  the  mucous  membrane  and  the  ves- 
sel leading  from  the  ha^morrhoid.  (After 
Pilcher.) 


Fig.  509. — The  same,  showing  the  tumor  clipped 
off  with  the  scissors  and  the  running  suture 
continued  through  the  base  of  the  hiemorrhoid 
and  over  the  forceps,  which  is  to  be  removed 
and  the  suture  drawn  tight.      (Pilcher.) 


apposition  throughout  the  entire  circumference,  and  it  is  of  greater  importance 
that  too  much  of  the  lining  membrane  be  not  sacrificed.  The  Barnes  dilator  or 
the  f>lug  should  be  removed  and  a  dressing  of  light  gauze  applied. 

It  is  a  common  practice,  in  order  to  permit  the  escape  of  gas  without  causing 
muscular  spasm,  to  insert  a  small  rubber  tube  not  more  than  one  quarter  of  an 
inch  in  diameter,  four  or  five  inches  into  the  bowel,  and  to  hold  it  in  place  by 
a  safety  pin  secured  in  the  outer  dressing.  The  bowels  should  be  moved  within 
twenty-four  hours  of  the  operation  by  irrigation  with  hot  normal  salt  solution. 

For  the  first  three  days  the  diet  should  be  liquids  or  very  light  semisolid 
ingesta.  After  this  solid  food  may  be  taken.  The  bowels  should  be  moved  once 
in  every  twenty-four  hours  by  the  administration,  preferably,  of  castor  oil,  next 
in  order  calomel  triturates,  2  to  2-J-  grains,  to  be  followed,  if  necessary,  by  Epsom 


RECTUM   A^D   ANUS  499 

salts.  Under  no  circumstances  should  fecal  matter  be  allowed  to  accumulate  and 
interfere  with  the  process  of  repair  by  overdistention. 

When  there  is  no  prolapse  of  the  mucous  membrane  and  when  there  are  only 
two  or  three  isolated  htemorrhoidal  tmnors,  the  rational  method  of  treatment  is 
to  deal  with  each  individual  tumor  as  advocated  by  Earle  and  A.  B.  Mitchell  and 
as  modified  by  L.  S.  Pilcher.^ 

When  the  sphincter  has  been  dilated  and  the  hsemorrhoids  stripped  down  to 
the  anal  margin,  the  tumor  should  be  joicked  up  by  the  mouse-tooth  forceps,  and 
the  small  narrow  curved  forceps,  with  a  bite  of  about  one  and  a  half  inches,  should 
be  made  to  grasp  the  tumor  parallel  with  the  long  axis  of  the  rectum  and  be 
tightly  clamped  (Fig.  508).  It  is  not  necessary  to  incise  the  mucous  membrane 
around  the  base  of  the  hemorrhoid. 

If  there  is  a  single  tumor  the  forceps  may  take  a  free  hold  of  the  mucous 
membrane,  but  when  there  are  two  or  more  tumors  to  be  removed,  if  too  much 
tissue  is  included  in  the  grasp  of  the  instrument  an  uncomfortable  narrowing  of 
the  bowel  outlet  may  result. 

It  is  better  to  err  on  the  safe  side  and  grasp  not  more, than  two  thirds  of  the 
mass,  as  the  remaining  third  will  be  constricted  by  the  continuous  suture.  After 
the  forceps  has  been  clamped,  the  tumor  and  mucous  membrane  should  be  cut 
away  with  the  scissors  to  within  about  one  eighth  of  an  inch  of  the  instrument. 
A  No.  3  ten-day  catgut  suture  is  now  inserted  as  follows : 

A  full-curve  Hagedorn  needle  is  carried  one  eighth  of  an  inch  beyond  the 
point  of  the  instrument  through  the  mucous  membrane  and  out  one  quarter  of 
an  inch  distant,  and  is  tied.  This  suture  secures  the  vascular  supply  of  the 
hsemorrhoid  and  prevents  subsequent  haemorrhage.  A  running  suture,  which  passes 
underneath  the  forceps  and  then  over  it  until  the  cut  surface  is  all  included,  is 
inserted,  and  the  forceps  is  then  unlocked  and  withdrawn  and  the  suture  tight- 
ened by  traction,  and  finally  tied  (Fig.  509). 

The  damp  and  cautery  operation  is  still  preferred  by  many  operators  of  large 
experience.  It  is  performed  as  follows:  After  stretching  the  sphincter,  the  tumor 
is  drawn  out  and  grasped  at  its  base  between  the  jaws  of  the  clamp  (Fig.  510), 
and  the  blades  closed  by  tightening  the  screw  in  the  handles  until  the  hemorrhoid 
is  strangulated.  It  is  advised  to  grasp  the  hemorrhoids  in  such  a  manner  that 
the  instrument  points  directly  up  the  bowel.  With  the  scissors  the  mass  is  cut 
away  about  one  fourth  of  an  inch  external  to  the  clamp,  and  the  cut  surface 
thoroiTghly  cauterized  with  the  Paquelin  or  the  actual  cautery.  The  ivory  plates 
upon  the  jaws  of  the  clamp  protect  the  mucous  membrane  of  the  bowel  from  being 
burned.     When  this  is  done,  the  blades   should  be  slowly  separated,  and,  if  any 


Fig.  510. — Smith's  hemorrhoidal  clamp  (ivory-plated). 

oozing  is  seen,  the  bleeding  point  should  be  again  touched  with  the  cautery.     The 
after-treatment  is  the  same  as  for  the  preceding  operation. 

In  capiUari/  ha^inorrlioids  the  chief  symptom  is  hemorrhage.  The  bleeding 
occurs  with  and  after  each  stool,  or  may  follow  violent  exercise  or  straining.  If 
the  finger  is  carried  into  the  bowel,  no  tumors  are  felt,  and  there  is  usually  no 
tenesmus.  If  the  speculum  is  employed,  the  mucous  membrane  will  be  seen  to 
be  studded  with  bleeding  points  or  tufts  projecting  a  slight  distance  from  the 
normal  level  of  the  lining  membrane  of  the  rectum.  They  are  red,  not  unlike 
small  raspberries  in  appearance,  and  bleed  profusely  at  the  slightest  provocation. 

1  "British  Medical  Jr.,"  February  28,  1905;  "Annals  of  Surgery,"  August,  1906. 


500  RECTUM   AND   ANUS 

They  are  really  new  formations  or  chronic  granulation  tissue,  rich  in  capillary 
loops. 

The  treatment  consists  in  dilatation  of  the  anus  and  rectum  with  the  speculum, 
and  in  touching  the  bleeding  points  with  the  Paquelin  or  hot-iron  cautery  until 
all  bleeding  ceases. 

Catarrhal  Inflammaiion  of  the  Rectum  and  Sigmoid. — Tuttle's  rectal  irrigator 
is  used  in  applying  either  hot  or  cold  water  in  irrigation,  as  may  be  indicated  in 
the  case  under  consideration.  Tuberculosis  is  now  recognized  as  the  setiologieal 
factor  in  a  number  of  conditions  about  the  anus  and  rectum.  It  may  develop 
primarily  or  secondarily  in  the  skin,  muco-cutaneous,  mucous  and  cellular  tissues 
(Tuttle).  The  miliary  form  is  rare,  developing  as  minute  nodules  or  infiltration, 
which  feel  like  small  shot  or  millet  seed  beneath  the  epidermis.  Practically  all 
varieties  end  in  ulceration.  The  typical  tubercular  ulcer  has  ragged,  irregular 
edges,  with  a  tendency  to  spread  from  the  cutaneous  margin  into  the  anal  mricous 
membrane. 

Treatment  is  local  and  constitutional.  Local  repair  is  scarcely  possible  unless 
the  general  resistance  of  the  patient  can  be  improved.  As  a  rule,  soothing  local 
applications  are  better  tlian  drying  powders. 

Primary  tuberculosis  of  the  low  portion  of  the  intestinal  tract  is  exceedingly 
rare,  and  is  almost  unknown  in  adults.  Secondary  to  the  disease  in  other  organs, 
it  is  comparatively  frequent.  The  diagnosis  is  difficult,  and  requires  careful  in- 
spection with  the  proctoscope.  They  are,  as  a  rule,  not  painful,  and  appear  as 
irregular  ulcers,  with  slightly  elevated,  sloping  bases,  surrounded  by  slightly  thick- 
ened and  undermined  edges  (Tuttle).  The  local  treatment  is  to  scrape  out, 
cauterize,  or  stimulate  the  ulcers,  and  to  improve  the  general  condition. 

Gonococcus  proctitis  is  a  rare  affection,  and  will  be  treated  of  in  another 
chapter.  The  jjarts  should  be  kept  clean  by  sponging  or  external  irrigation  with 
mercuric  chloride,  l-20'OO,  and  intra-anal  irrigation  with  permanganate  of  potash 
solution. 

Anal  chancroids  are  treated  in  the  same  way  as  are  those  of  other  portions  of 
the  body.  Herpes  of  the  anus  appears  as  one  or  more  groups  of  elevated  vesicles, 
in  which  is  an  accumulation  of  clear,  milky  white  serum.  They  sometimes  co- 
alesce, to  form  a  large  bleb  (Tuttle).  They  usually  break  down  and  leave  large  raw 
surfaces.  The  bleb  should  be  opened,  the  thin  covering  excised,  the  parts  washed 
with  1-3000  mercuric-chloride  solution,  warm,  and  a  drying  powder,  such  as 
aristol,  applied. 

Eczema  of  this  region  should  be  treated  by  improving  the  general  condition 
of  the  patient.  Application  of  warm  water,  to  which  is  added  a  small  quantity 
of  ))icarbonate  of  soda,  is  one  of  the  most ,  soothing  local  applications.  The  sur- 
faces should  not  be  irritated.  Oxide-of-zinc  ointment  is  one  of  the  best  local 
remedies. 

Pruritus  Ani. — This  distressing  affection  is  a  symptom  of  a  number  of  diseases 
connected  with  the  peritonaeum,  vulva,  and  anus.  It  is  at  times  due  to  the  pres- 
ence of  parasites,  certain  forms  of  pediculi,  and  to  the  trichophyton  or  fungus 
which  produces  eczema  marginatum.  It  is  found  in  the  superficial  layers  of  the 
epidermis,  and  is  readily  transmissible.  The  spores  or  mycelia  may  be  recognized 
by  examining  under  the  microscoiDC  a  small  scraping  of  the  epidermis,  treated 
with  diluted  liquor  potassi.  The  application  of  hyposidphite  of  sodium,  one  dram 
to  the  ounce  of  water,  or  an  ointment  of  about  the  same  proportion,  will  effect  a 
cure.  Eczema  and  herpes  also  cause  itching.  Not  infrequently  pruritus  is  caused 
by  a  small  parasite,  the  ascaris  vermicularis,  which  infests  the  lower  end  of  the 
alimentary  canal.  Hfemorrhoids  are  another  cause.  Among  various  remedies, 
combination  of  carbolic  acid,  2  drams,  salicylic  acid,  1  dram,  and  glycerine,  1 
dram,  applied  by  means  of  a  camel's-hair  iDrush  or  on  a  swab,  after  bathing 
in  hot  water,  is  highly  recommended.  Mathews  recommends  campho-phenyl,  1 
dram,  distilled  water,  1  ounce,  applied  as  a  lotion  after  the  application  of  hot 
water,  repeating  frequently  if  necessary.  Chloral  hydrate,  10  to  30  grains,  in 
glycerine  and  water,  often  affords  instant  relief.  When  there  is  an  erythematous 
or  eezematous  condition  about  the  margins  of  the  anus,  ichthyol,  10  parts,  boric 


RECTUM   AND  ANUS  501 

acid,  5  parts,  and  lanolin,  85  parts,  will  relieve  the  distressing  symptoms.  Diachy- 
lon ointment  has  also  been  found  of  use.  Professor  Tuttle  recommends  highly 
the  following  formula  of  Adler :  Fluid  extract  hamamelis,  5j ;  fl.  ext.  ergot,  §ij ; 
fl..  ext.  hydrastis,  5j ;  comp.  tinct.  benzoin,  5ij ;  carbolized  olive  or  linseed  oil,  §j ; 
and  carbolic  acid  (five-per-cent  strong),  gj-  Shake  well  before  using  and  apply 
externally. 

N"itrate  of  silver  in  solutions  of  from  two  to  twenty-five  per  cent  are  among 
other  more  heroic  remedies  prescribed.  When  the  parts  are  dry  and  iissured, 
Tuttle  recommends  painting  with  flexible  collodion,  and  to  mix  one  per  cent  of 
ichthyol  with  this  in  cases  where  there  is  considerable  thickening  of  the  skin. 
"  With  all  these  applications,  the  parts  should  be  protected  from  rubbing  on  each 
other  with  pledgets  of  cotton  or  gauze.  Every  case  of  pruritus  is  a  problem  in 
itself." 

Allingham  noticed  that  pressure  over  the  anus  would  relieve  the  sensation  of 
pruritus,  and  advised  the  introduction  of  a  specially  formed  plug  into  the  anus 
at  bedtime,  keeping  it  there  by  a  bandage  throughout  the  night.  Occasionally  this 
brings  relief.  All  local  catarrhal  conditions  should  he  carefully  treated,  diseases 
of  digestive  disorders  corrected,  and  general  constitutional  treatment  combined 
with  local  measures. 


CHAPTER    XXYII 

GENITO-UEINARY     ORGANS KIDNEYS PYELITIS,     PYELONEPHRITIS,     HYDRONEPHRO- 
SIS,    NEPHROLITPIIASIS — URETERS 

Wounds. — Eupture  of  the  kidney  may  occur  not  only  directly  from  a  pene- 
trating wound,  but  from  a  blow  without  penetration  inflicted  over  this  organ, 
and  indirectly  as  from  a  fall  from  a  height,  striking  on  a  remote  part  of  the  body 
as  the  buttocks  or  feet.  The  immediate  symptom  is  haemorrhage,  which  is  pro- 
portionate to  the  extent  of  the  injury  and  especially  to  the  location  of  the  wound 
in  the  kidney.  If  only  a  limited  area  of  the  cortex  is  torn,  the  bleeding  may  not 
be  dangerous,  but  where  the  larger  vessels  near  the  hilum  are  involved,  alarming 
hffimorrhage  may  occur,  while  shock,  vomiting,  pallor,  cold  perspiration,  rapid 
and  weak  pulse,  are  present  in  the  majority  of  such  cases.  Pain  is  severe,  at  times 
and  is  felt  not  only  in  the  region  of  the  organ,  but  is  transmitted  in  the  direction 
of  the  ureters  into  the  bladder,  producing  tenesmus,  extending  down  the  leg,  and 
in  males  to  the  testicle,  of  that  side  which  is  generally  retracted  toward  the  ex- 
ternal ring.  Extravasation  of  urine  takes  place,  and  when  the  capsule  is  torn  it 
ma}'  find  its  way  either  .through  a  posterior  rupture  into  the  loose  areolar  tissue- 
of  the  retroperitoneal  space,  or,  in  cases  of  anterior  rupture  of  the  capsule,  it  may 
escape  into  the  peritoneal  cavity.  Hfemorrhage  occurs  also  into  the  uriniferous 
tubules  and  pelvis  of  the  kidney,  gravitating  along  the  ureters  into  the  l}ladder, 
where  it  may  be  in  evidence  in  the  discharged  urine.  At  times  blood  clots  form 
either  in  the  ureters  or  in  the  pelvis  of  the  kidney,  preventing  the  urine  from 
flowing  into  the  bladder  and  producing  what  may  be  mistaken  for  partial  sup- 
pression of  urine,  the  urine  from  this  kidney  being  discharged  either  into  the  retro- 
peritoneal space  or  through  an  external  wound,  if  such  exists.  There  may  be, 
however,  as  a  result  of  injury  and  the  consequent  shock,  a  partial  suppression 
of  urine  without  regard  to  the  occlusion  of  the  ureter  on  one  side.  The  more 
remote  symptoms  of  rupture  of  the  kidney,  which  are  met  with  usually  from 
twelve  to  twenty-four  hours  after  the  injury,  are  increased  localized  tenderness, 
distention  or  swelling  in  the  lumbar  region,  and  exacerbations  of  temperature, 
with  or  without  rigors  or  chills,  due  to  septic  infection  either  from  urine  which 
is  not  sterile  or  through  the  external  opening. 

Treatment. — The  immediate  indication  is  the  arrest  of  haemorrhage,  and  when 
the  conditions  are  alarming  this  should  he  done  by  immediate  incision  over  the 
known  location  of  the  organ,  and  the  hteinorrhage  controlled  either  by  packing 
with  sterite  gauze  when  the  cortical  substance  alone  is  involved,  or  by  direct  suture 
with  sterile  catgut  through  the  cortical  substance  when  the  location  of  the  rup- 
ture and  the  character  of  the  haemorrhage  will  require.  When  the  larger  vessels 
near  the  hilum  are  involved,  direct  ligature  at  the  bleeding  point  is  advisable,  or, 
in  cases  of  great  depletion,  where  valuable  time  would  l)e  sacrificed  in  the  effort 
to  find  the  bleeding  points,  a  temporary  ligature  en  masse  to  the  pedicle  of  this 
organ  will  be  justifiable.  In  counteracting  the  dangerous  effects  of  such  haemor- 
rhage, the  immediate  injection  of  a  hot  saline  solution  is  of  inestimable  value. 
When  septic  infection  has  occurred,  as  will  be  determined  by  the  symptoms  just 
given,  careful  exploration  with  an  aspirating  needle,  under  cocaine  anaesthesia, 
should  be  made  at  the  point  -of  selection  (usually  that  of  greatest  tenderness), 
and  if  pus  is  discovered,  an  incision  should  be  made,  the  pus  evacuated,  and  the 
wound  irrigated  with  mercuric-chloride  solution  (1-10,000)  and  drained  with  a 
rubber  tube  or  iodoformized  gauze  wick.     Even  when  pus  cannot  be  discovered 

502 


GENITO-URINARY   ORGANS  503 

by  the  aspirating  needle,  incision  is  indicated  if  there  are  pronounced  symptoms 
of  sepsis.  The  Ividney  may  be  easily  reached  by  a  perpendicular  incision  extend- 
ing from  an  inch  above  the  level  of  the  last  rib  three  or  four  inches  down^vard 
parallel  with  the  spines  of  the  lumbar  vertebrae  and  from  three  to  three  and  a  half 
inches  from  these  spines.  It  is  located  just  in  front  of  the  outer  border  of  the 
quadratus  lumborum  muscle,  its  lower  extremity  reaching  nearly  to  the  umbilicus. 
Should  the  organ  be  practically  destroyed  as  the  result  of  injury,  free  drainage 
will  secure  safety,  and  some  time  should  elapse — usually  six  weeks  to  three  months 
— before  removal  of  the  disintegrated  organ  should  be  undertaken,  in  order  to 
enable  the  remaining  kidney  to  become  accustomed  to  its  increased  function. 

The  kidney  is  often  the  seat  of  morbid  changes,  which  occur  partly  from  inter- 
nal violence  (calculus),  or  structural  changes,  which  may  at  times  demand  sur- 
gical interference.  Pyelitis,  pyoneplirosis,  hydronephrosis,  nephrolithiasis,  tuher- 
culosis,  gumma,  and  certain  new  formations,  as  cysts,  carcinoma,  sarcoma,  rhahdo- 
myo7na,  adenoma,  and  angeioma  are  among  the  chief  diseases  of  a  surgical  nature. 

Pyelitis,  Pteloxephkitis,  and  Hydronepheosis 

Pyelitis,  an  inflammation  of  the  pelvis  and  calices  of  the  kidney,  is  of  frequent 
occurrence.  When  the  substance  of  the  kidney  becomes  involved  it  is  known  as 
pyelonephritis.  In  extreme  cases  the  whole  kidney  may  be  converted  into  an 
immense  abscess,  divided  and  subdivided  by  trabecule,  but  limited  by  the  original 
distended  capsule.  Inflammation  of  the  renal  pelvis,  rrncomplicated  with  any 
other  lesion  of  the  urinary  apparatus,  rarely  develops  symptoms  appreciable  to 
the  patient  or  surgeon.  When  it  assumes  surgical  proportions  it  is  usually  second- 
ary to  a  pathological  condition  somewhere  in  the  genito-urinary  tract.  A  frequent 
cause  is  nephrolithiasis.  A  stone  or  calculus  lodged  in  the  pelvis  induces  inflam- 
mation by  its  presence  or  by  obstruction  of  the  ureter,  and  causes  a  distention  of 
the  pelvis  with  urine  (hydronephrosis),  or  when  pus  Is  present  with  the  retained 
urine  (hydro-pyonephrosis).  Or  the  disease  may  be  due  to  an  ascending  inflam- 
mation, ureteritis,  cystitis,  or  urethritis,  or  to  an  obstruction  to  the  outflow  of 
"urine,  caused  by  an  enlarged  prostate,  or  tumor,  or  urethral  stricture,  with  over- 
distention  of  the  bladder  and  ureters  and  renal  pelvis,  ultimately  destroying  the 
substance  of  the  kidney. 

The  disease  is  usually  bilateral  unless  caused  by  renal  calculus  or  stricture  of 
the  ureter  on  one  side.  Another  frequent  cause  of  pyelitis  and  pyelonephritis  is 
tuberculosis,  which  is  often  secondary  to  a  tubercular  focus  in  the  lungs  or  else- 
where. The  prolonged  use  of  blennorrhetics — cantharides,  turpentine,  cubebs,  etc. 
— improperly  employed  in  the  treatment  of  gonorrhoea,  may  cause  an  active  con- 
gestion of  the  kidney,  from  which  pyelitis  or  pyelonephritis  results.  The  pregnant 
uterus,  or  uterus  enlarged  from  other  causes,  may,  by  pressure  upon  the  ureters, 
cause  pyelitis.  In  rare  instances  violence  from  without  may  be  a  cause,  and  the 
■disease  may  also  result  from  a  suppurative  inflammation  surrounding  the  kidney 
(perinephritis).  Certain  systemic  infectious  diseases,  such  as  scarlet  fever,  diph- 
theria, osteomyelitis,  etc.,  are  associated  with  pyelitis  and  pyelonephritis.  In 
ihese  cases,  however,  the  inflammation  rarel}^  proceeds  to  recognizable  pus  forma- 
tion, and  its  presence  is  overshadowed  by  the  gravity  of  the  primary  disease. 

Direct  extension  of  an  acute  gonorrhoeal  inflammation  of  the  kidney,  as  given 
by  Keyes,  is  not,  as  a  rule,  associated  with  appreciable  renal  symptoms. 

Diagnosis. — Pyelitis  and  pyelonephritis  are  nearly  always  associated  with 
symptoms  of  cystitis.  A  chill  occurring  during  the  course  of  a  cystitis  suggests 
pyelitis.  The  history  of  an  antecedent  attack  of  renal  colic,  a  dull  pain  in  the 
loin  radiating  down  the  course  of  the  ureter  and  inner  side  of  the  thigh,  with 
retraction  of  the  testicle  on  that  side,  are  strong  evidence  of  the  presence  of  this 
disease.  In  long-standing  pyelonephritis  a  tumor  may  be  made  out  by  deep  pal- 
pation. Tubercular  pyelitis  may  be  suggested  by  the  presence  of  tubercular  dis- 
ease elsewhere.  Careful  examination  of  the  urine  is  the  most  important  step  in 
diagnosis.  The  sudden  disappearance  of  the  pain,  decline  in  temperature,  and 
symptoms  of  sepsis,  with  an  exaggerated  quantity  of  pus  in  the  urine,  should  con- 


504  GENITO-URINARY  ORGANS 

firm  the  diagnosis.  These  cases  of  explosiTe  pyelonephritis  are  not  uncommon. 
The  reaction  of  the  urine  to  litmus  paper  is  of  importance.  In  pyelitis  the  urine 
is  excessively  acid,  remaining  so  for  several  days  upon  standing,  with  a  greenish, 
oily  deposit  of  pus  and  deiris,  while  in  severe  cystitis,  without  involvement  of  the 
kidney,  the  urine  is  neutral  or  even  alkaline  from  ammoniacal  decomposition. 
Under  the  microscope,  pus,  mucus,  occasionally  hyaline  and  granular  casts,  blood 
corpuscles,  and  epithelial  cells,  peculiar  to  the  renal  pelvis,  are  found.  In  the 
diagnosis  of  this  disease  the  cystoscope.  may  be  iised  with  advantage  to  determine 
if  it  be  unilateral  or  bilateral.  The  bladder  should  be  thoroughly  washed  out  with 
warm  boric-acid  solution  to  free  it  from  all  pus  and  mucus,  then,  with  about  half 
a  pint  of  this  solution  in  the  bladder,  the  cystoscope  should  be  carefully  introduced 
through  the  urethra  and  inverted,  holding  the  mirror  well  above  the  floor  of  the 
trigonum,  the  electric  light  turned  on,  and  search  made  for  the  urethral  outlet. 
The  boiling  up  of  pus,  mucus,  and  shreds  from  the  ureter  which  leads  down  from 
the  diseased  kidney  can  readily  be  seen.  A  ready  means  of  diagnosis  is  to  wash 
the  bladder  out  thoroughly,  and  after  fifteen  or  twenty  minutes  to  collect  the 
urine  by  the  introduction  of  a  clean  Nelaton  catheter.  If  the  pus  is  abundant 
and  evenly  mixed  with  the  urine,  it  undoubtedly  comes  from  the  kidney. 

Treatment. — When  pyelonephritis  exists  exploration  and  drainage  are  indi- 
cated with  removal  of  the  kidney,  if  the  condition  demands  it.  As  a  rule,  how- 
ever, it  is  safer  to  delay  the  nephrectomj^  until  after  several  months  of  drainage  in 
order  not  only  to  build  up  the  condition  of  the  patient  by  the  arrest  of  septic 
absorption,  but  to  accustom  the  opposite  organ  gradually  to  the  additional  labor 
placed  upon  it.  In  milder  eases  the  treatment  of  the  disease  is  usually  the  treat- 
ment of  the  cause.  The  cystitis  should  be  treated  by  rest  in  bed,  warm  fomenta- 
tions over  the  bladder  and  kidney  to  relieve  pain,  diluent  drinks,  and  the  adminis- 
tration of  salol,  oil  of  wintergreen,  or  other  sterilizing  diuretics  internally; 
occasionally   irrigation   of  the  bladder  with  warm  boric-acid   solution  is   of   ad- 


Urethral  strictures  should  be  divided,  obstructing  tumors  removed,  or  the 
bladder  drained;  stone  in  the  ureter  or  kidney  pelvis,  if  made  out,  should  be 
removed  by  direct  incision.  Tuberculosis  of  the  kidney,  if  unilateral,  cannot  be 
cured  other  than  by  nephrectomy. 

Hydronephrosis. — Hydronephrosis,  the  gradual  distention  of  the  pelvis  of  the 
kidney  caused  by  an  accumulation  of  the  urine  from  an  obstruction  to  its  outflow, 
is  usually  attended  by  more  or  less  atrophy  of  renal  substance.  It  sometimes 
reaches  enormous  dimensions,  and  again  may  be  so  small  as  to  escape  observation. 
The  condition  is  always  a  primary  stage  of  pyelonephritis.  Chronic  hydrone- 
phrosis nearly  always  results  in  a  suppurative  inflammation.  It  is  either  a  con- 
genital or  an  acquired  lesion.  When  congenital,  it  is  the  result  of  partial  or  com- 
plete occlusion  of  the  ureter  or  urethra.  When  acquired,  it  is  the  result  of  an 
impacted  calculus  in  the  ureter,  or  stricture  of  this  tube,  pressure  of  pelvic  tumors, 
growths  in  the  bladder  encroaching  upon  the  urethral  or  ureteral  outlet,  flexion 
of  the  ureter  due  to  movable  kidney,  enlarged  prostate  in  old  men,  and  urethral 
strictures. 

The  diagnosis  is  quite  difficult  unless  the  swelling  is  sufficiently  large  to  attract 
the  attention  by  its  size  or  to  cause  symptoms  of  compression  of  the  abdominal 
organs.  In  most  cases  where  the  obstruction  is  not  permanent  but  recurs  at  inter- 
vals, the  disappearance  of  the  swelling  with  the  discharge  of  an  extraordinary 
quantity  of  urine  is  a  positive  sjanptom  of  hydronephrosis.  Pain  may  be  absent 
or  excruciating  in  character.  Pressure  of  the  tumor  upon  the  overlying  colon 
may  give  rise  to  disturbance  in  this  tube.  Ursemia  is  at  times  present  and  of 
serious  character  when  the  disease  is  bilateral.  A  positive  diagnosis  can  be  made 
with  safety  by  exploratory  puncture  with  an  aspirating  needle.  The  disease  may 
coexist  with  a  hydatid  or  an  ovarian  cyst,  or  cyst  of  other  organs  in  the  region 
of  the  kidney,  such  as  the  pancreas  or  spleen,  or  with  abdominal  ascites.  In  the 
latter,  however,  the  level  of  the  fluid  changes  with  the  different  positions  assumed, 
and  the  history  of  an  antecedent  liver  trouble  almost  always  precedes  ascites.  Hy- 
datid vesicles  are  found  in  the  urine  or  obtained  by  exploratory  puncture,  and 


GENITO-URINARY   ORGANS  505 

enable  us  to  diagnose  this  cyst,  wliieh  is  rarely  bilateral,  while  hydronephrosis  is 
frequently  so.  Cysts  of  the  spleen  and  pancreas  are  rare,  and  the  early  history  of 
their  origin  will  poiat  away  from  the  kidney. 

In  the  treatment  of  hydronephrosis,  attention  should  be  directed  to  prophy- 
laxis. .  The  diagnosis  of  nephrolithiasis,  enlarged  prostate,  or  urethral  stricture 
should  demand  the  surgeon's  attention  before  hydronephrosis  results.  In  the 
majority  of  cases,  with  moderate  tumefaction,  operative  measures  are  not  indi- 
cated. Symptoms  of  ursemia  call  for  warm  baths,  diaphoretics,  and  purgatives, 
in  the  effort  to  eliminate  by  the  skin  and  bowels  the  necessary  quantity  of  urea. 
When  large  enough  to  interfere  with  the  comfort  of  the  patient,  or  when  well- 
marked  sepsis  supervenes,  the  fluid  should  be  evacuated.  If  suppuration  has  re- 
sulted in  the  sac,  preference  should  be  given  to  free  incision.  The  wall  of  the 
cyst  may  be  stitched  to  the  abdominal  wound,  or  if  urgent  symptoms  be  not 
present,  the  dissection  may  be  carried  down  to  the  cyst  capsule  and  the  wound 
packed  with  sterilized  gauze  for  a  day  or  two,  until  adhesions  have  taken  place, 
after  which  the  contents  should  be  evacuated.  In  milder  cases  a  sterile  aspirator 
needle  should  be  introduced  at  the  most  prominent  part  of  the  obstruction  near 
the  last  rib,  and  the  contents  removed.  Injections  of  iodine,  carbolic  acid,  and 
other  irritating  substances  should  not  be  practiced.  Impacted  calculus  demands 
removal. 

Nephrolithiasis 

The  most  frequent  condition  of  nephrolithiasis  is  where  the  urinary  salts  are 
precipitated  in  crystalline  form  within  the  kidney  tubules,  pelvis,  or  other  portion 
of  the  urinary  tract.  A  gouty  or  rheumatic  diathesis  predisposes  to  gravel.  A 
renal  stone  is  formed  by  these  small  urinary  crystals  aggregating  around  a  nucleus 
of  epithelium,  mucus,  blood  clot,  or  other  organic  substance.  Although  chiefly 
composed  of  uric  acid  in  various  combinations,  or  oxalic  acid  in  combination  with 
lime,  these  calculi  may  be  as  variable  in  composition  as  those  to  be  considered  in 
connection  with  diseases  of  the  bladder.  According  to  analyses  made  by  Taylor 
of  the  calculi  in  the  Hunterian  Museum,  those  occurring  in  children  are  chiefly 
muriate  of  ammonia;  in  adult  life,  uric  acid;  and  after  forty  years  of  age,  oxalate 
of  lime.  They  may  be  found  in  the  substance  of  the  kidney,  in  the  pelvis,  or 
projecting  from  one  into  the  other;  more  frequently,  however,  they  are  met  with 
in  the  pelvis  of  the  kidney.  A  kidney  stone  may  be  single,  in  size  varying  from 
small  particles  of  sand  to  several  ounces  in  weight;  or  there  may  be  several  hun- 
dred small  ones  of  irregular  size,  round  and  smooth  by  mutual  friction. 

The  symptoms  are  variable.  Unless  severe  pyelitis  supervenes,  or  mechanical 
obstruction  to  the  outflow  of  urine  from  the  pelvis  by  impaction  in  the  ureter 
is  evident,  the  patient's  attention  may  not  be  attracted  to  the  kidney.  If,  how- 
ever, sudden  occlusion  of  the  ureter  ensues,  it  produces  symptoms  of  great  dis- 
tress. If  the  stone  is  small  and  smooth,  it  may  find  its  way  into  the  bladder 
without  much  pain;  but  when  large  enough  to  distend  the  ureter,  or  rough,  pain 
is  extreme.  It  may  be  constant  or  spasmodic,  and  is  usually  referred  to  the 
neighborhood  of  the  impaction.  In  males  the  testicle  of  the  affected  side  is 
drawn  up  toward  the  external  ring,  and  the  pain  may  radiate  down  the  thigh  and 
leg.  Vomiting  may  be  present.  The  duration  of  the  attack  varies  from  a  few 
hours  to  days.  When  the  stone  escapes  into  the  bladder  the  relief  is  as  sudden 
as  the  attack.  In  some  instances,  however,  it  becomes  hopelessly  impacted.  The 
presence  of  blood  in  the  urine  is  important  in  connection  with  the  pain,  especially 
so  when  it  is  increased  by  exercise  and  diminished  after  rest  in  bed.  The  micro- 
scope may  also  show  epithelial  cells  characteristic  of  the  renal  pelvis.  The  dis- 
covery of  small  calculi  that  have  passed  with  the  urine  confirms  the  diagnosis. 

Treatment. — In  patients  known  to  have  the  uric-acid  diathesis,  or  when  the 
characteristic  brick-dust  deposit  is  in  the  urine,  the  kidneys  should  be  flooded  by 
administering  large  quantities  of  alkaline  water,  and  by  sterilization  of  the  urine 
with  salol  and  gaultheria,  as  heretofore  given;  such  patients  should  be  advised 
to  live  on  a  low  diet,  largely  vegetable,  to  abstain  from  alcoholic  liquors,  and  to 
take  plenty  of  outdoor  exercise.     The  urine  should  be  examined  occasionally,  and 


506  GENITO-URINARY   ORGANS 

if  found  very  acid,  thirty  grains  of  citrate  of  jTOtassium  in  a  large  tumbler  of 
-water  should  be  given  three  times  a  day.  When  the  paroxysms  of  pain,  due  to 
the  passage  of  the  stone  through  the  ureter,  occur,  morphine  or  chloroform  should 
be  used  to  allay  the  extreme  suffering.  A  hot  bath  and  fomentations  may  be  used 
with  benefit.  In  extreme  cases  and  when  the  stone  is  known  to  have  become  im- 
pacted, exploratory  operation  should  be  done  and  the  stone  carefully  removed. 
Should  the  kidney  be  entirely  destroyed  by  the  presence  of  a  large  number  of 
stones  or  by  pyelonephritis  and  the  disease  be  confined  to  one  kidney,  the  question 
of  nephrectomy  may  be  entertained.  If  a  portion  of  the  kidney  is  still  capable 
of  excreting  urine,  it  is  advisable  to  pack  the  wound  and  allow  it  to  heal  by 
granulation.  If  the  stone  be  not  found  in  the  renal  substance  or  pelvis,  the  whole 
fength  of  the  ureter  must  be  palpated.  The  operations  of  nephrotomy  and  ureter- 
otomy are  described  on  another  page. 

Cysts  of  the  Kidney. — Cystic  tumors  are  occasionally  encountered  in  the  kid- 
ney. They  are  caused  by  an  obstruction  along  the  course  of  the  uriniferous  tu- 
bules, causing  a  dilatation  or  cyst  formation  from  retention  of  the  urine,  are 
usually  small,  and  may  be  single  or  multiple.  The  conglomerate  variety  is  a 
true  cystic  degeneration  of  the  kidney,  and  is  rare.  Both  kidneys  are  usually  in- 
volved, and  for  this  reason  the  prognosis  is  grave.  The  degeneration  continues 
with  the  formation  of  cysts,  until  in  course  of  time  all  trace  of  kidney  substance 
disappears.  AYhen  bilateral,  surgical  treatment  is  not  called  for.  Hydatid  cysts, 
due  to  the  lodgment  of  the  ova  of  the  Twnia  ecliinococcus,  are  met  with  occasion- 
ally in  the  kidney.  The  tumor  may  become  so  large  as  to  be  mistaken  for  an 
ovarian  cyst.  Pressure  symptoms  on  the  contiguous  viscera  or  distinct  bulging  in 
the  region  of  the  affectecl  organs  will  proljably  be  the  only  indication  of  its  pres- 
ence. A  differential  diagnosis  between  these  renal  cysts  may  be  made  by  aspira- 
tion. The  fluid  from  a.  hydronephrosis  would  be  urine ;  that  from  a  simple  or 
conglomerate  cyst,  albuminous;  while  fluid  from  a  hydatid  would  contain  the 
characteristic  hooklets.  It  is  a  safe  rule  in  practice,  when  a  tumor  of  the  kidney 
becomes  large  enough  to  be  appreciated  by  palpation  and  inspection,  and  should 
prove  to  be  cystic  in  character,  to  evacuate  the  contents.  This  may  be  done  by 
aspiration  or,  better,  by  an  incision  into  the  cyst,  stitching  the  cyst  wall  to  the 
edges  of  the  wound. 

Solid  Tumors  of  the  Kidney. — Of  the  solid  tumors  which  affect  the  kidney, 
sarcoma  is  the  most  frequent;  it  occurs  chiefly  in  the  young,  and  is  occasionally 
congenital.  Carcinoma  of  the  kidney  usually  assumes  the  (so-called)  encephaloid 
form,  less  frequently  the  melanotic.  A  rare  form  of  tumor  known  as  rhabdomyoma 
or  myosarcoma  sometimes  occurs  in  this  organ.  In  the  differentiation  between 
sarcoma  and  carcinoma  of  the  kidney  the  only  guide  is  the  age  of  the  patient, 
for,  as  Just  said,  sarcoma  occurs  almost  always  in  the  young,  and  carcinoma  rarely 
before  the  thirtieth  year  of  life.  The  presence  of  a  tumor  solid  in  character  in 
the  region  of  the  kidney,  with  symptoms  of  pressure  upon  the  ureter,  renal  vein, 
or  ascending  vena  cava,  and  displacement  of  the  mass  downward  in  the  direction 
of  the  navel,  would  indicate  the  presence  of  a  solid  neoplasm.  Pressure  upon  the 
spermatic  vein  in  the  male  may  produce  varicocele.  Exploration  with  a  view  to 
extirpation  is  the  only  way  to  confirm  the  diagnosis  as  soon  as  a  solid  neoplasm  is 
recognized.  In  the  removal  of  large  sarcomata  in  children,  and,  in  fact,  in  all 
operations  upon  large  vascular  tumors  of  the  body,  the  Trendelenburg  posture  is 
preferable,  since  the  gravitation  of  the  blood  to  the  chest  and  to  the  upper  ex- 
tremity lessens  the  danger  of  haemorrhage.  In  some  of  these  cases  a  long  trans- 
verse incision  from  the  middle  line  to  the  quadratus  lumborum,  combined  with 
the  perpendicular  lumbar  incision,  is  essential  to  the  safe  removal  of  renal  neo- 
'  plasms. 

Fibroma  of  the  kidney  has  been  met  with  in  few  instances,  and,  while  not  a 
malignant  growth,  it  should  be  removed,  since  it  produces  great  discomfort  by 
displacing  the  organ. 

Movable  and  Floating  Kidney. — The  kidney  may  be  displaced  directly  by  a 
blow  over  the  seat  of  this  organ,  or  indirectly  by  a  fall  from  a  height,  the  indi- 
Tidual   striking  upon  the   feet,   stretching  or  rupturing  the  fascial,  attachments. 


GEXITO-URINARY   ORG.\NS  507 

It  may  also  be  displaced  by  tight  lacing  in  women,  especially  on  the  right  side, 
where  expansion  of  the  chest  is  interfered  with  and  the  liver  forced  downward 
upon  the  kidney  in  the  inspiration  act.  It  may  also  be  displaced,  as  just  said, 
by  increased  weight  due  to  hydronephrosis  and  the  development  of  tumors  in  con- 
nection with  it.  Eapid  absorption  of  the  perirenal  fat — as  in  pregnancy  or  in 
disease — adds  to  the  tendency  of  this  organ  to  gravitate  from  its  normal  position. 
Displacement  of  the  kidney  may  also  be  congenital.  In  a  case  which  came  under 
my  observation  the  kidney  was  found  in  the  pelvis. 

A  kidney  is  said  to  be  '"  floating "'  when  it  has  descended  so  far  that  it  has 
pushed  the  peritonaeum  ahead  of  it  and  is  encapsulated  in  the  peritouEeum,  in 
the  same  manner  as  the  testicle  in  its  descent.  It  is  "  movable  "  when  it  is  dis- 
placed but  not  encapsulated  by  peritonaeum. 

Diagnosis. — A  thickened  and  enlarged  gall  bladder,  a  tumor  of  the  colon,  or 
mesentery,  or  omentum,  shoidd  be  carefuUj^  excluded.  In  one  instance  a  loljular 
prolongation  of  the  right  lobe  of  the  liver,  in  shape  not  unlike  the  kidney,  was 
mistaken  by  me  for  a  floating  kidnej' — which  organ  was  found  in  its  proper  place. 
Opening  into  the  peritoneal  cavity,  the  tumor  was  found  to  be  a  projection  from 
the  liver  with  tlie  gall  bladder  attached.  It  was  connected  with  the  liver  by  a 
well-defined  isthmus  about  two  inches  wide  and  one  fourth  of  an  inch  in  thickness. 
The  presence  of  a  tumor  in  the  lower  portion  of  the  hypochondriac  or  in  the 
lumbar  region,  in  shape  conforming  to  that  of  the  kidney  reducible  in  the  direc- 
tion of  the  normal  position  of  this  organ,  and  disappearing  by  gravitation  in  the 
same  direction  when  the  pelvis  is  well  elevated,  are  physical  signs  which  point 
decidedly  to  a  misplaced  kidney. 

Bimanual  palpation  will  aid  in  the  diagnosis.  It  can  be  best  recognized  with 
the  patient  in  a  semireclining  position,  with  the  abdominal  muscles  entirely  re- 
laxed. Certain  symptoms,  such  as  renal  colic,  due  to  overlapping  or  doubling  of 
the  ureter  and  its  temporary  occlusion,  or  a  dragging,  peculiar,  and  sickening  sen- 
sation which  accompanies  this  lesion,  should  be  of  value  in  arriving  at  a  correct 


The  treatment  of  this  condition  is  surgical  in  all  cases  in  which  the  condition 
•of  the  patient  will  justify  operative  interference. 

Nephropexy  by  the  following  method  is  advised:  The  patient  is  placed  in  the 
prone  position  with  an  inflated  rubber  bag  or  soft  cushion  beneath  the  abdomen 
just  above  the  umbilicus.  The  incision  begins  over  the  center  of  the  twelfth  rib 
and  runs  downward  to  the  crest  with  a  slight  obliquity  toward  the  anterior-superior 
spine  of  the  ilium.  The  muscular  fibers  should  be  separated  by  blunt  dissection 
as  far  as  possible,  and  only  divided  when  sufficient  room  cannot  otherwise  be 
•obtained.  Any  blood  vessels  encoimtered  should  be  clamped  with  two  forceps 
divided  between  and  immediately  secured  with  catgut.  The  nerves  should  be  held 
aside  with  retractors,  and  when  it  becomes  necessary  to  divide  one  or  more,  each 
•end  should  be  marked  at  once  by  a  fine  silk  or  linen  thread  introduced  by  means 
of  a  small  needle  in  the  sheath  near  the  end.  When  the  wound  is  being  closed, 
these  ends  should  be  carefully  approximated. 

When  the  kidney  is  exposed  and  drawn  well  into  the  wound,  the  fatty  capsule 
should  be  stripped  off  by  dry  dissection  and  an  incision  made  in  the  capsule  proper 
throughout  the  whole  extent  of  the  convex  border.  With  dull-pointed  scissors  the 
capsule  should  be  lifted  from  the  body  of  the  organ  for  about  one  inch  and  everted. 
Two  sutures  of  silkworm  gut  upon  long  quarter-curved  Hagedorn  needles  should 
now  be  passed  through  the  integument  near  the  edge  of  the  wound  directly  through 
the  capsule,  and  the  substance  of  the  kidney  from  one  half  to  three  fourths  of 
an  inch  from  the  convex  border,  and  again  through  the  skin  near  the  point  of 
entrance,  where  the  two  ends  are  tied  together.  These  two  sutures  passing  partly 
through  the  substance  of  the  kidney  will  hold  the  organ  in  position  better  than 
those  passing  through  the  friable  capsule.  The  eversion  of  the  capsule  is  done 
to  secure  permanent  adhesions  between  the  kidney  and  the  neighboring  tissues. 
Four  or  five  ten-day  chromicized  catgut  sutures  may  be  used  in  stitching  the 
capsule  to  the  hmibar  fascia  if  deemed  necessary.  The  wound  shoidd  then  be 
•  closed  with  the  ordinary  aseptic  precautions.     The  silkworm-gut  loops  are  removed 


508  GENITO-URINARY   ORGANS 

about  the  tenth  or  fifteenth  day  by  dividing  one  end  of  the  loop  and  making  a 
traction  npon  the  other. 

Nephrectomy  is  a  much  more  difficult  procedure,  and  is,  in  fact,  one  of  the 
more  formidable  operations  and  requires  a  larger  incision.  To  the  perpendicular 
lumbar  incision,  as  just  given,  may  be  added  a  transverse  cut  running  from  near 
the  center  of  the  perpendicular  incision.  When  the  organ  is  greatly  enlarged  it 
may  be  necessar}'  to  open  the  peritonseum,  carefully  guarding  from  infection  by 
packing  with  sterile  mats.  It  is,  of  course,  advisable  not  to  open  the  peritonasum 
when  this  can  be  avoided,  but  so  great  is  the  danger  from  hasmorrhage  in  dealing 
with  the  large  vessels  of  the  hilum  that  it  is  safer  in  many  procedures  to  adopt 
the  transjDeritoneal  route.  It  is  at  times  necessary  to  apply  a  clamp  to  the  entire 
pedicle,  remove  the  diseased  organ,  and  then  secure  the  vessels  separately  before 
the  clamp  is  removed. 

In  eases  of  tuberculosis  of  the  hidney  and  ureter  this  should  also  be  removed, 
and  it  may  be  necessary  to  extend  the  incision  obliquely  downward  along  the  crest 
of  the  ilium  in  order  to  reach  the  ureter  at  its  lowest  point.  In  the  removal  of 
very  large  tumors  the  author  has  found  the  incision  along  the  linea  semilunaris 
preferable.  This  incision  is  continued  until  the  peritoneal  cavity  over  the  kidney 
is  freely  opened.  The  intestines,  especially  the  descending  colon  and  the  splenic 
flexure,  are  displaced  toward  the  median  line  and  carefully  guarded  with  hot  steril- 
ized pads.  After  the  kidney  has  been  removed,  the  wormd  through  the  posterior 
layer  of  the  peritonaeum  should  be  closed  by  catgut  sutures  and  the  anterior  wound 
treated  after  the  usual  manner. 

Uketees 

Congenital  lesions  of  the  ureter  rarely  call  for  surgical  interference.  Occa- 
sionally this  tube  comes.  ofE  from  the  kidney  in  a  normal  position  and  ends  in  a 
cul-de-sac,  or  a  valve  may  be  present  which  prevents  the  escape  of  urine  into  the 
bladder.  Instead  of  entering  the  bladder,  the  ureter  may  open  into  the  canal 
of  the  urethra  in  either  sex ;  or  occasionally  it  may  terminate  in  the  vagina.  Cases 
have  been  reported  where  two  or  more  ureters  or  prolonged  calices  proceeded  from 
one  kidney  and  united  below  in  a  single  tube.  If  any  of  these  conditions  can  be 
determined,  the  operative  treatment  would  require  either  a  removal  of  the  kid- 
ney or  the  transfer  of  the  end  of  the  ureter,  first,  into  the  bladder,  if  this  be 
possible,  or  out  through  the  integument  at  the  most  convenient  point  to  establish 
the  urinary  fistula.  In  all  such  operations  it  is  essential  before  extirpation  of  the 
kidney  to  determine  the  presence  and  condition  of  the  opposite  organ.  If  there 
are  two  kidneys,  one  of  these  being  normal,  it  is  advisalsle  to  remove  the  ofEendiug 
organ  rather  than  to  lead  the  ureter  into  the  vagina  or  intestinal  canal,  on  account 
of  the  discomfort  j^roduced  by  this  procedure  and  the  danger  of  ascending  infection. 

There  are  three  narrowings  in  the  normal  ureter,  the  first  about  one  and  a 
half  inch  from  the  pelvis  of  the  kidney;  the  second,  at  the  point  of  crossing  of 
the  iliac  artery;  the  third,  at  the  entrance  into  the  muscular  wall  of  the  bladder. 
It  is  at  these  points  that  calculi  or  inflammatory  matter,  pus,  etc.,  drifting  down- 
ward from  the  pelvis  are  apt  to  lodge. 

The  ureter  is  a  musci^lar  cylinder,  varying  in  length  from  ten  to  flfteen  inches. 
It  descends  in  a  slightly  curved  line  from  the  kidney  to  the  urinary  bladder, 
and  its  relation  to  the  peritouffium  should  be  carefully  studied.  ISTormally  it  is 
so  firmly  adherent  to  this  membrane  that  when  the  peritonaeum  is  lifted  the  ureter 
goes  with  it.  In  retroperitoneal  operations  it  may  be  easily  found  attached  to  the 
peritonasum  and  running  about  half  an  inch  external  to  "the  line  of  adhesion  of 
this  membrane  to  the  spinal  column. 

Traumatic  lesions  of  the  ureter  may  occur  from  penetrating  wounds  and  (in 
certain  cases  of  fracture)  from  projecting  particles  of  bone,  or  perforation  may 
occur  from  the  pressure  of  an  impacted  calculus.  The  treatment  demands  ex- 
posure of  the  seat  of  injury,  suture  of  the  divided  ends  of  the  canal,  as  will  be 
described  hereafter,  or,  if  this  is  not  possible,  the  establishment  of  an  external 
urinary  fistula,  after  which  at  some  proper  time  the  removal  of  the  kidney  of  that 
side  may  be  considered.     Impaction  of  a  calculus  in  the  ureter  may  be  determined 


GENITO-URINARY   ORGANS 


509 


by  the  symptoms  already  given  in  the  section  on  nephrolithiasis,  and  in  addition 
the  X-ray  may  be  called  into  requisition. 

Deaver  advises  opening  the  pielvis  of  the  kidney  and  introducing  a  long  probe 
or  sound  into  the  ureter  until  the  stone  is  encountered.  If  the  lodgment  has  oc- 
curred at  the  two  lower  contractions,  palpation  by  the  rectum  or  vagina  for  the 
lower,  and  direct  palpation  through  the  abdominal  wall  for  the  upper  narrowing, 
may  succeed  in  locating  the  stone.  An  incision  may  be  necessary  to  a  correct 
diagnosis,  especially  when  the  stone  is  located  in  the  upper  contraction,  and,  when 
found,  if  the  stone  cannot  be  crushed  between  the  thumb  and  finger,  the  ureter 
should  be  opened  and  the  calculus  removed. 

Willard  Bartlett  ^  advises  an  incision,  which  is  not  necessarily  extensive,  par- 
allel to  the  external  Iwrder  of  the  rectus  muscle,  extending  upward  from  near  the 
pubis  as  far  as  required.  The  peritonaeum  is  exposed,  but  not  opened,  and  gently 
pushed  toward  the  iniddle  line,  the  hand  of  the  operator  keeping  as  close  as  pos- 
sible to  this  membrane,  which  will  drag  the  ureter  into  the  wound,  so  intimate 
is  the  attachment  between  them. 

With  the  tube  between  the  thumb  and  first  finger  of  the  left  hand,  the  ureter 
is  followed  and  the  stone  located.  The  stone  is  tightly  held  between  the  thumb 
and  tirst  finger  of  the  left  hand  while  the  wall  of  the  ureter,  which  is  stretched 
over  the  stone,  is  nicked  with  the  point  of  a  sharp  knife,  and  the  foreign  body  is 
then  squeezed  through  the  tiny  opening  which  stretches  to  accommodate  its  pas- 
sage. No  stitches  are  taken  in  the  \ireter,  the  small  wound  closing  spontaneously. 
A  fine  cigarette  drain  is  carried  down  to  the  vicinity,  and  the  abdomen  closed  except 
at  the  lower  angle.  ^ 

Longitudinal  wounds  of  the  ureter  which  communicate  with  the  peritoneal 
cavity  should  be  closed  by   direct  suture,   and  in  all   such  operations   thorough 


Fig.  511. — Fenger's  method  for  relief  of  stricture  of  the  ureter. 


drainage  should  be  secured.  When  longitudinal  wounds  of  the  ureter,  accidental 
or  incised,  do  not  open  into  the  peritoneum,  it  is  not  necessary  to  employ  sutures, 
since  such  wounds  usually  close  by  granulation. 

In  dealing  with  the  ureter,  the  extraperitoneal  route  should  be  used  whenever 
possible.  Cicatricial  stenosis,  if  not  too  extensive,  should  be  treated  by  Fenger's 
method.     Make  a  longitudinal  incision  through  the  contracted  portion;  bring  the 

>  "Surg.,  Gyii.  and  Obst.,"  September,  1907. 

2  Bartlett  rejiorts  four  operations  successful  in  this  manner,  with  no  leakage. 


510 


GENITO-URINARY   ORGANS 


upper  and  lower  ends  of  the  incision  together  by  folding  the  nreter  upon  itself, 
and  unite  the  contiguous  surfaces  to  each  otlier  with  silk  sutures   (Fig.  511). 

To  e-xpose  the  ureter  in  the  retroperitoneal  space,  malvC  an  incision  from  the 
last  rib  to  near  the  iliac  crest,  parallel  to  and  three  and  a  half  inches  from  the 
vertebral  spine.  From  the  anterior  spine,  when  necessary,  the  incision  should  be 
extended  inward  and  downward  to  near  the  center  of  Poupart's  ligament.  Upon 
reaching  the  peritouasum,  this  is  carefully  detached  and  raised  by  the  finger  until 
its  line  of  adhesion  to  the  spinal  column  is  reached.  The  ureter  will  be  found 
adhering  to  the  peritonaeum  from  half  an  inch  to  one  inch  from  the  line  of  adhe- 
sion of  the  membrane  to  the  spinal  column.  On  account  of  the  position  of  the 
vena  cava  aseendens  on  the  right  side,  the  line  of  adhesion  is  somewhat  more 
external. 

In  transverse  wounds  with  complete  division,  efforts  at  direct  suture  and  re- 
union have  all  failed  on  account  of  the  great  difficulty  of  manipulation  in  so  deep 
a  situation  and  the  retraction  and  separation  of  the  ends.  The  more  rational 
procedure  is  to  form  a  fistula  by  transferring  the  end  of  the  upper  portion  of  the 
divided  tube  to  the  integument  at  a  convenient  point,  usually  near  the  kidney 


No.  2. 
Fig.  512. — Van  Hook's  method  of  anastomosis  of  the  divided  ureter. 


posteriorly.  For  security,  a  ligature  may  be  applied  to  the  lower  end.  The  ques- 
tion of  nephrectomy  will  be  a  later  consideration. 

Implantation  into  the  bowel  is  such  a  great  inconvenience  to  the  patient,  as  a 
rule,  and  accompanied  by  such  risk  of  ascending  infection,  that  it  is  scarcely 
advisable. 

In  Van  Hook's  operation  invagination  of  the  upper  into  the  lower  segment  has 
been  successfully  performed.  "  Ligate  the  lower  portion  of  the  tube  one  eighth 
or  one  fourth  of  an  inch  from  the  end  with  silk ;  with  fine,  sharp-pointed  scissors, 
make  a  longitudinal  incision  beginning  one  fourth  of  an  inch  below  the  ligature. 


GENITO-URINARY   ORGANS 


511 


the  opening  to  be  twice  as  long  as  the  diameter  of  the  ureter.  In  the  upper  portion 
of  the  ureter,  with  scissors,  make  an  incision  beginning  at  the  open  end  of  the 
duct  and  carrj'ing  it  up  one  fourth  of  an  inch.  Pass  two  very  small  cambric  sew- 
ing needles,  armed  with  a  single  catgut  thread,  through  the  wall  of  the  upper 
end  of  the  urethra,  one  eighth  of  an  inch  from  the  extremity  and  from  within 
outward,  the  needles  to  be  one  sixteenth  to  one  eighth  of  an  inch  apart  (Fig.  513). 
These  needles  are  now  carried  througli  the  slit  in  the  side  of  the  lower  end  of 
the  ureter  into  and  down  the  tube  for  half  an  inch,  where  they  are  pushed  through 
the  wall  of  the  duct  side  by  side.  By  traction  upon  this  catgut  loop  pulling  upon 
the  two  cambric  needles,  the  upper  segment  of  the  duct  is  drawn  into  the  lower 


Fig.  513. — Direct  ocular  in;ipcction  and  catheterization  of  tlie  ureters  in  the  female.     (Howard  Kelly.) 


segment.  This  being  done,  the  ends  of  the  catgut  thread  are  tied  together  securely. 
The  ureter  is  now  carefully  enveloped  with  peritona?um  and  fine  silk  sutures  in- 
serted, passing  only  through  the  muscular  laj'er  "   ( Figs.  Xo.  3  and  3 ) . 

AVhen  only  the  "lower  portion  of  the  ureter  is  to  be  explored,  an  incision  parallel 
with  Poupart's  ligament,  beginning  about  at  its  center  and  extended  upward  in  the 
general  direction  of  the  anterior-superior  spine  and  the  fibers  of  the  aponeurosis 
of  the  external  oblique  will  be  sufficient.  The  peritonfeum  is  displaced  inward  as 
soon  as  it  is  encountered,  the  whole  procedure  being  retroperitoneal.  When  re- 
moval of  the  ureter  at  its  attachment  to  the  bladder  is  necessary,  it  may  be  divided, 
and  the  ligature  is  not  essential  for  the  reason  that  the  valvular  arrangement  of 
the  entrance  of  this  tube  into  the  bladder  prevents  regurgitation  of  the  urine.  A 
cigarette  drain  or  tube  should  always  be  left  in  place  as  a  matter  of  precaution. 
This  may  be  removed  in  two  to  four  days  as  indicated. 

In  several  instances  in  which  a  ligature  has  been  placed  upon  the  upper  end 
of  the  divided  ureter,  where  so  much  has  been  removed  that  end-to-end  reunion 
was  impossible,  and  where  the  upper  end  could  not  be  transplanted  into  the  blad- 
der, it  has  resulted  in  an  arrest  of  the  function  in  the  kidney  on  that  side. 

When  a  calculus  is  extracted  by  any  of  these  methods,  the  wound  should  be 
packed  and  careful  gauze-wick  drainage  established,  the  wound  being  allowed  to 
heal  by  granulation. 


512 


GENITO-URINARY   ORGANS 


It  is  at  times  essential  to  transfer  the  end  of  a  divided  ureter  into  the  blad- 
der. The  method  suggested  by  Van  Hook  and  successfully  performed  by  Prof. 
I'lorian  Krug  is  as  follows:  The  left  ureter  having  been  divided,  a  small  opening 
was  made  into  the  bladder  and  the  end  of  the  upper  section  of  the  ureter  carried 
through  this  wound.  Several  rows  of  carefully  inserted  silk  sutures  attached  the 
tube  to  the  wound  in  the  bladder,  care  being  taken  not  to  permit  the  needle  to 
penetrate  through  the  muscular  layer  into  the  lumen  of  the  tube.     Careful  cathe- 


FiG.  514, — Suction  apparatus. 

terization  was  practiced- in  order  to  keep  the  bladder  empty  and  to  prevent  leakage 
by  h3'perdistention.  Ascending  infection  of  the  kidney  is  apt  to  follow  ureteral 
transplantation. 

Catheterization  of  the  Ureters — Method  of  Kelly. — Direct  exploration  of  the 
ureter  and  irrigation  of  the  pelvis  of  the  kidney  through  this  tube  is  done  as 
follows :  The  apparatus  required  consists  of  a  female  catheter,  a  conical  urethral 
dilator  and  several  specula  with  obturators,  a  common  head  mirror,  a  lamp  with 
an  Argand  burner  or  electric  droplight,  a  pair  of  long,  delicate  mouse-tooth  for- 
ceps, a  suction  apparatus  for  completely  emptying  the  bladder,  a  ureteral  searcher, 
a  ureteral  catheter  without  any  handle,  cushions  for  elevating  the  pelvis,  or  an 
inclined  plane. 

Careful  cocainization  of  the  urethra  will  in  many  instances  enable  the  operator 
to  examine  the  bladder  and  catheterize  the  ureters  practically  without  pain.  Should 
necessity  demand,  general  narcosis  may  be  employed. 


Fig.    515.— DUator. 


The  patient  is  placed  upon  the  back  near  the  edge  of  the  table  with  the  pelvis 
elevated  as  shown  in  Pig.  513.  The  bladder  is  completely  emptied  by  catheter 
and  the  suction  apparatus  (Fig.  514).  The  conical  graduated  dilator  (Fig.  515) 
is  gently  bored  into  the  external  orifice  of  the  urethra  until  it  is  dilated  as  much 
as  eight  or  ten  millimetres.  A  speculum  corresponding  to  the  size  indicated  by 
the  dilator  is  next  introduced,  holding  the  handle  at  iirst  well  above  the  level 
of  the  external  meatus,  carrying  the  end  on  through  the  urethra  and  into  the 
bladder  by  gently  sweeping  the  hand  downward  and  inward  over  the  symphysis. 
The  obturator  is  now  withdrawn,  and  the  bladder  at  once  fills  with  air,  with  an 
audible  suction  sound.     If  the  air  does  not  rush  in,  the  hips  of  the  patient  are 


GENITO-URINARY   ORGANS 


513 


still  further  elevated  (from  twelve  to  sixteen,  inches  above  the  level  of  the  table, 
Fig.  513).  With  the  head  mirror  attached,  an  electric  droplight  or  bright  lamp 
is  held  close  to  the  patient's  symphysis  pubis  to  make  the  angle  of  reflection  as 


518)  may 


J^G.  517. 
Forceps. 


Fig.  516. — Speculum. 

small  as  possible.  Kow,  by  properly 
directing  the  light,  all  parts  of  the 
bladder  are  easily  accessible  to  direct 
inspection.  Any  urine  which  has  col- 
lected during  the  dilatation  can  be  re- 
moved through  the  speculum  by  the 
suction  apparatus,  or  by  cotton  pellets 
held  by  the  mouse-tooth  forceps  (Fig. 
517).  By  exposing  the  trigonum  and 
turning  the  sjDeculum  about  thirty  de- 
grees to  one  side  or  the  other,  the  ori- 
fices of  the  ureters  are  seen.  The  urine 
will  appear  at  short  intervals  in  jets 
from  the  orifice;  in  pathological  con- 
ditions, pus  and  blood  may  be  seen 
coming  from  one  ureter  while  the  other 
discharges  normal  urine.  The  mucous 
membrane  of  the  bladder  is  usually  of  a 
deeper  rose-color  near  the  orifice  of  the 
ureter;  at  times  it  is  deej^ly  injected.  The  searcher  (Fig 
be  introduced  through  the  speculum  into  a  suspected  ureteral  orifice, 
which,  if  found,  will  allow  the  searcher  to  pass  in  for  several  centi- 
meters. The  latter  is  then  withdrawn  and  the  ureteral  catheter 
(Fig.  519)  introduced.  By  leaving  this  catheter  in  the  ureter  for 
a  few  minutes,  the  urine  wliicli  descends  from  the  kidney  of  that 
side  will  be  discharged  through  it,  while  the  urine  from  the  opposite 
side  collects  in  the  emptied  bladder,  thus  affording  an  opportunity 
to  make  a  separate  analysis  of  the  urine  of  each  kidney.  The  diag- 
nostic value  of  this  practice  is  evident.  If  the  patient  is  stout,  or 
if  the  bladder  for  any  reason  does  not  readily  distend  with  air,  the 
inspection  will  be  best  conducted  in  the  knee-breast  posture. 

PavjJiTc's  Method. — Free-hand  ureteral  catheterization  is  prac- 
ticed in  the  following  way:  The  patient  is  brought  with  the  but- 
tocks to  the  edge  of  the  table,  with  the  legs  and  thighs  sharply 
flexed.  The  vulva  and  vagina  are  cleansed  with  soap  and  water 
and  the  urine  drawn  from  the  bladder  and  preserved  for  inspection. 
The  bladder  is  then  injected  with  a  solution  of  methyl  blue,  about 
six  ounces.  The  posterior  vaginal  wall  is  now  retracted  with  a 
Sims  speculum,  which  exposes  the  anterior  wall.  On  elose  inspec- 
tion two  prominent  folds  will  be  seen  sweeping  over  the  anterior 
wall  about  half-way  up  and  out  to  the  sides  on  to  the  lateral  walls 
toward  the  cervix.  These  are  the  "ureteral  folds"  of  Pawlik,  the 
pioneer  in  this  method.  Parallel  to  and  just  above  these  folds 
the  ureters  are  to  be  sought.  Kelly's  ureteral  sound  is  now  intro- 
duced tlirough  the  urethra  into  the  bladder  and  held  with  the 
concavity  of  its  tip  toward  the  floor  of  the  bladder.  A  little  pres- 
sure on  the  floor  reveals  its  position  to  the  eye,  which  is  kept  on 
the  vaginal  wall.     It  is  now  guided  in  the  direction  of  the  ureteral 


514  GENITO-URINARY   ORGANS 

folds  and,  should  it  catch  in  the  ureteral  orifice,  it  will  at  once  be  felt  to  have  a 
determinate  direction  as  it  slips  backward  and  outward  toward  the  jjosterior  pelvic 
wall.     The  ureter  may  now  be  palpated  on  the  sound.     If  the  catheter  is  in  the 


Fig.    518. — Searcher. 


Fig.  519. — Catheter. 

ureter,  after  waiting  a  few  minutes,  the  urine  begins  to  flow,  drop  by  drop, 
clear  and  unmixed  with  the  methyl  solution,  demonstrating  that  it  is  being 
collected  at  a  point  above  the  bladder.  For  the  recognition  of  stricture  or 
stone  in  the  lower  portion  of  the  ureter,  this  method  is  invaluable. 

There  is  always  such  a  very  considerable  danger  of  introducing  infection  into 
the  ureter  by  catheterization  that  when  any  other  method  of  securing  a  specimen 
of  urine  from  one  or  the  other  ureter  for  differentiation  may  be  employed,  this 
should  be  used.  This  may  be  done  by  the  Luys  separator.  This  instrument, 
shaped  like  a  catheter,  is  introduced  into  the  bladder,  and  should  be  held  accu- 
rately in  the  median  line  imbedding  the  convex  surface  of  its  curve  deeply  in 
the  trigonum  and  posterior  bladder  wall.  The  bladder  should  be  thoroughly  washed 
owt  and  all  the  residual  fluid  removed.  The  mechanism  of  Luys'  separator  is 
so  arranged  that  the  diaphragm  or  partition  may  be  lifted  from  the  concave 
surface  of  the  instrument,  and  this  prevents  the  urine  descending  from  one  ureter 
to  be  mixed  with  that  from  the  other.  As  it  trickles  into  the  bladder  it  is  carried 
out  on  either  side  of  the  diaphragm  through  a  separate  catheter.  In  this  way 
a  differential  study  can  be  made  of  the  excretion  from  the  two  kidneys  without 
any  danger  of  infecting  a  healthy  ureter. 


CHAPTER    XXVIII 

THE      BLADDER CONGENITAL      MALF0E5I ATIONS WOUNDS HERNIA CYSTITIS 

SUPPRESSION INCONTINENCE NEOPLASMS THE    URINE CALCULUS LITHOT- 

RITY — CYSTOTOMY FOREIGN    BODIES 

Congenital  malformations  of  the  bladder  are  fortunately  rare.  There  may 
be  complete  absence  of  this  organ,  the  ureters  opening  directly  on  the  surface  or 
into  the  vagina  or  rectum;  there  may  be  more  than  one  bladder  or  a  normal  blad- 


FiG.  520. — Double  penis.      Case  in  practice  of  Dr.  J. 
D.  Cole,  of  Tennessee. 


-Exstrophy  of  the  bladder, 
hermaphrodite. 


der  divided  into  two  parts  by  a  septum.  In  these  cases  in  the  male  there  may  be 
a  double  penis  with  a  separate  urethra  to  each  bladder.  In  the  case  of  the  child 
(Fig.  520)  born  in  1894  there  are  two  organs,  "  each  penis  perfectly  formed,  one 

515 


516  THE   BLADDER 

a  little  to  the  left  of  the  median  line  and  a  little  lower  than  the  other,  which  is 
nearly  in  the  middle  line.  They  are  one  fourth  of  an  inch  apart  at  the  level  of 
the  skin.  He  passes  a  good  stream  of  urine  through  both  urethrse  at  the  same 
time.  A  single  urethra  in  the  perinajum  bifurcates  into  a  channel  for  each  penis. 
The  scrotum  is  divided  into  three  compartments.  The  right  and  left  compart- 
ments contain  each  one  testicle,  and  in  the  middle  pouch  is  something  which 
feels  like  a  testicle.  The  anus  was  imperforate.  I  operated  by  an  incision  three 
inches  in  depth,  when  the  blind  end  {cul-de-sac)  of  the  rectum  was  found  and  . 
freely  opened."  ^     The  child  recovered,  and  is  now  living  at  two  years  of  age. 

Exstrophy,  or  eversion  of  the  bladder  (Fig.  521),  is  almost  always  met  with 
in  males.  It  is  caused  by  a  failure  of  development  in  the  anterior  pelvic  and  ab- 
dominal regions.  The  integument,  muscles,  pubic  bones,  and  anterior  part  of  the 
bladder  wall  are  missing.  Through  this  gap  the  part  of  the  bladder  which  may 
be  present  is  protruded,  as  a  mass  of  variable  size  (depending  upon  the  extent  of 
the  deformity  and  upon  the  position  of  the  patient),  from  one  inch  up  to  three 
or  four  inches  in  diameter.  In  the  erect  posture  it  is  always  largest,  being  pushed 
out  by  the  descent  of  the  abdominal  viscera,  and  may  be  complicated  by  hernia 
of  the  intestine.  The  mucous  membrane,  which  covers  the  mass,  is  in  appearance 
not  unlike  a  recent  non-strangulated  prolapsus  ani.  The  orifices  of  the  ureters 
may  be  found  opening  at  some  point  on  the  lower  portion  of  the  protrusion,  and 
are  often  considerably  dilated.  In  all  cases  of  exstrophy  the  genital  apparatus 
is  rudimentary.  The  penis  is  wholly  or  in  great  part  wanting.  The  urethra  may 
1)6  seen  as  a  simple  groove,  into  which  the  seminal  ducts  enter.  The  scrotum,  at 
times  entirely  absent,  may  in  other  cases  be  present,  lodging  the  testicles,  or  it 
may  be  bifid,  with  one  organ  in  each  sac,  or  entirely 
missing,  the  testes  remaining  in  the  abdomen,  or 
lodged  in  the  groin  or  thigh. 

The  degree  of  exstrophy  varies  in  proportion  to 
the  extent  of  the  malformation.  In  the  more  favor- 
able cases  the  pubic  bones  are  almost  united  at  the 
symphysis,  and  the  protrusion  consequently  small. 

In  females  the  genital  organs  are  also  rudimentary. 
The  clitoris,  nymphee,  vagina,  and  uterus  may  be  ab- 
sent or  displaced,  and  only  partially  develojjed.  The 
general  appearances  of  the  tumor  are  the  same  in  both 
sexes. 

In  males  the  condition  of  bifid  scrotum  and  ab- 
sence of  the  penis  resembles  somewhat  the  normal 
genitals  of  the  female,  the  so-called  hermaphrodite. 

Exstrophy  of  the  bladder,  even  in  a  mild  form, 
is  a  source  of  great  annoyance. 

The  treatment  is  chiefly  palliative,  and  consists  in 
the  application  of  an  apparatus,  with  or  without  oper- 
ative interference,  to  drain  the  urine  and  prevent  ex- 
coriations.    A  suitable  instrument  is  shovm  in  Fig. 
523.    The  operative  treatment  consists  in  an  effort  to  cover  in  the  protruding  mass 
by  integument  borrowed  from  the  immediate  vicinity  of  the  tumor. 

The  chief  difficulty  lies  in  protecting  the  flaps  from  suppuration  excited  by 
contact  with  septic  urine.  Silkworm-gut  or  silver-wire  sutures  are  always  to  be 
used.  To  protect  the  flaps  from  the  urine,  Levis'  procedure  more  nearly  meets 
the  indications.  It  consists  of  establishing  a  false  urethra  from  that  portion  of 
the  undeveloped  bladder  near  the  orifice  of  the  ureters  through  the  perinseum. 
A  large,  long  needle  armed  with  good-sized  thread  or  wire  is  passed  through  the 
wall  of  the  bladder  just  at  the  opening  of  the  ureters  and  brought  out  in  the 
perinaeum  just  in  front  of  the  anus.  The  wire  is  allowed  to  remain  as  a  seton, 
and  through  the  fistula  thus  established,  and  enlarged  by  interrupted  dilatation 
with  bougies,  the  urine  flows.    If  necessary,  the  testicles  may  be  removed  and  the 

'  Personal  communication  from  Dr.  J.  D.  Cole,  of  Newbem,  Tennessee,  to  author. 


THE   BLADDER 


517 


skin  of  the  scrotum  used  to  line  this  false  passage.  When  this  is  accomplished, 
the  second  stage  of  the  operation  consists  of  covering  the  exstrophy  with  integu- 
ment turned  over  from  the  immediate  neighborhood  of  the  deformity.  Wood's 
method   (Figs.  523  and  52-1)   consists  of  three  flaps,  two  lateral  and  one  central. 


Fig.  523. — Wood's  method.     Outline  of 


Fig.  524. — The  same  after  the  sutures 
have  been  applied. 


The  central  one  should  be  square,  its  width  at  least  one  third  greater  than  the 
defect  to  be  covered;  its  length  suiBcient  to  cover  the  bladder  space  completely 
when  turned  down,  also  allowing  one  third  for  contraction.  The  flaps  should  con- 
sist of  skin  and  superiieial  fascia.  The  two  lateral  pear-shaped  flaps  are  now 
dissected  up  from  the  groin  with  breadth  equal  to  the  length  of  the  first  flap  and 
length  equal  to  the  width  of  the  defect  to  be  covered.  These  flaps  when  dissected 
up  are  reflected  across  the  reversed  abdominal  flap,  meeting  in  the  median  line 
and  united  with  silver-wire  or  silkworm-gut  sutures.  These  sutures  should  with- 
out complete  perforation  include  a  portion  of  the  thickness  of  the  abdominal  flap, 
so  as  to  keep  the  surfaces  in  contact.  The  defleieneies  left  after  the  removal  of 
the  flaps  should  be  drawn  as  nearly  together  by  sutures  as  possible.  Any  space 
which  cannot  be  covered  is  allowed  to  granulate  or  is  repaired  later  by  grafting. 
A  perfect  functional  result  is  not  to  be  hoped  for  in  view  of  the  absent  sphincter. 
Some  form  of  apparatus  to  control  the  urine  will  always  have  to  be  worn. 


Hernia  Vesica,  or  Cxstocele 

Hernia  of  the  bladder  is  of  very  rare  occurrence.  In  the  male  it  usually  occurs 
through  the  inguinal  canal,  and  is  almost  always  associated  with  some  form  of 
intestinal  or  omental  hernia.  It  rarely  descends  into  the  scrotum.  In  the  female 
it  usually  takes  the  form  of  a  cystocele  into  the  vagina.  It  occurs  most  often  in 
the  aged  and  in  those  who  have  atonic  and  dilated  bladders.  The  bladder  becomes 
top-heay\'  and  flabby,  and  readily  prolapses  into  the  patidous  inguinal  canal.  It 
is  important  that  a  correct  diagnosis  be  made,  as  the  condition  may  simulate 
hydrocele  of  the  cord,  and  thus,  under  error  of  diagnosis,  be  incised.  The  prac- 
tical point  in  diagnosis  is  the  diminished  size  of  the  tumor  after  micturition  or 
withdrawal  of  the  urine  by  catheter. 

The  treatment  consists  in  restoring  the  organ  to  the  normal  position,  as  the 
hernia  which  it  complicates  is  cured  bj^  radical  operation. 

The  prolapse  of  this  organ  in  females  (cystocele)  will  be  considered  in  the 
chapter  on  gj-naecolog}'. 

WOUXDS    OF    THE    BLADDER EuPTURE 

Wounds  of  the  bladder  may  be  caused  by  penetration  from  without,  as  from 
a  stab  or  gunshot  wound,  by  rupture  from  overdistention,  by  violent  concussion 
over  the  lower  abdominal  region  when  the  organ  is  even  only  partially  distended, 
by  instrumentation,  and  by  direct  injury  from  displaced  fragments  of  the  pelvic 
bones.     Penetratinsc  wounds  of  the  bladder  are  rare,  not  onlv  on  account  of  the 


518 


THE   BLADDER 


protection  afforded  by  the  pelvis,  but  because  its  usual  condition  is  that  of  only 
partial  distention.  This  is  especially  true  of  wounds  received  in  military  practice, 
since  the  majority  of  soldiers,  under  the  excitement  which  attends  going  into 
action,  voluntarily  empty  this  organ. 

A  distinction  should  be  made  between  bladder  wounds  which  communicate  with 
the  peritoneal  cavity  and  those  which  penetrate  the  organ  in  that  part  of  its  sur- 
face not  covered  with  peritonasum. 

Diagnosis. — The  diagnosis  of  a  penetrating  wound  of  the  bladder  will  depend 
npon  the  escape  of  urine  through  the  external  opening,  should  the  situation  of 
the  external  wound  be  favorable  for  the  discharge  of  urine,  the  presence  of  blood 

or  foreign  matter  of  any  kind  in  the 
urine  drawn  by  catheter,  severe  pain 
over  the  region  of  the  bladder,  con- 
stant desire  with  inability  to  pass 
water,  and  usually  profound  shock. 
If  these  pioints  are  considered,  to- 
gether with  the  receipt  of  an  injiiry, 
a  penetrating  wound,  or  the  coexist- 
ence of  a  disease  of  the  bladder  wall, 
01  an  obstruction  to  the  outflow  of 
urine  from  any  cause,  the  diagnosis 
should  be  readily  made.  It  must  be 
remembered  that  the  sjonptoms  dif- 
fer considerably  according  to  the  loca- 
tion of  the  wound.  If  the  posterior 
or  peritoneal  surface  is  perforated, 
the  urine  will  escape  into  the  peri- 
toneal cavity,  producing  in  most  cases 
rapidly  supervening  sj^mptoms  of  peri- 
tonitis, accompanied  with  extreme 
prostration  ("abdominal  shock"). 
This,  however,  does  not  occur  in  all 
cases,  and  in  rare  instances,  when  the 
urine  is  aseptic,  it  may  remain  in 
the  peritoneal  cavity  for  many  hours 
without  producing  infection  or  any 
marked  syinjDtoms  of  peritoneal  in- 
flammation. When  the  perforation  is 
through  that  part  of  the  bladder  wall 
not  covered  by  peritonseum,  there  oc- 
curs usually  rapid  and  widespread 
infiltration  of  the  loose  connective 
tissue  of  this  region,  followed  by 
symptoms  of  oedema  and,  in  the 
jjresence  of  septic  urine,  rapid  rise 
of  temiDerature,  pain,  and  rigors,  and  the  usual  23henomena  of  septic  infection 
and  pus  formation.  Wounds  of  the  bladder  are  rare  in  children,  and  naturally 
much  more  frequent  in  men  than  in  women,  the  projjortion  being  ten  to  one. 

The  diagnosis  may  be  confirmed  by  introducing  a  catheter  through  the  urethra, 
which  usually  gives  escape  to  a  small  quantity  of  bloody  urine.  If  an  aseptic 
solution,  such  as  boiled  water  of  proper  temperature  (120°  F.),  or  boric-acid  solu- 
tion, be  carefully  measured  and  injected,  it  will  be  found,  if  there  is  a  perforation, 
that  the  quantity  returned  through  the  catheter  will  be  considerably  less  than 
that  injected,  as  a,  certain  portion  will  escape  through  the  rupture,  and  will  not 
reenter  the  bladder.  If  there  be  no  rupture,  the  distention  of  the  bladder  by  the 
injected  liquid  will  be  evident  by  percussion  above  the  symphysis  pubis. 

In  rupture  of  the  bladder  from  overdistention  where  no  injury  has  been  re- 
ceived, the  history  of  the  case  is  one  of  long  retention  and  overdistention,  great 
suffering,  constant  desire  to  urinate,  and  finallj'  a  feeling  as  if  something  had  given. 


Fig  >J"5 — Iho  iciationb  of  the  pentonEeum  to  the 
bl  uldcr  v.\un  distended  (After  Tarnier  )  1, 
llie  situation  of  the  tngonum  vesicce.  2,  Pros- 
tatic urethra. 


THE   BLADDER  519 

way,  followed  hj  partial  or  complete  temporary  relief  from  the  pressure  within 
the  bladder. 

The  prognosis  in  rupture  of  the  bladder  is  always  grave,  the  gravity  depending 
in  good  part  upon  the  location  and  extent  of  the  opening.  If  the  urine  escapes 
into  the  peritoneal  cavitj',  death  is  inevitable  unless  operation  is  performed  in 
the  first  few  hours  of  the  extravasation,  and  even  then,  if  the  urine  be  markedly 
septic,  the  ratio  of  mortality  is  high.  In  extraperitoneal  rvipture  the  prognosis  is 
more  favorable. 

Treatment. — The  indications  are  to  establish  the  diagnosis  at  the  earliest  pos- 
sible moment  after  the  receipt  of  the  injury  by  the  use  of  the  methods  just  advised, 
and  when  these  fail  and  the  character  of  the  injury  is  not  clear,  an  exploratory 
operation  is  advisable.  If  the  diagnosis  be  clear,  operation  is  imperative.  In 
intraperitoneal  rupture,  nothing  is  left  but  to  perform  laparotomy  in  the  median 
line  between  the  umbilicus  and  the  s}'mphysis  pubis,  taking  care  not  to  lase  the 
Trendelenburg  posture  or  to  elevate  the  pelvis,  for  fear  that  extravasated  urine 
may  be  brought  in  contact  with  peritoneal  surfaces  not  yet  involved  in  the  infec- 
tion. The  escaped  urine  should  l^e  removed  by  careful  sponging,  and  the  pelvic 
basin  thoroughly  flushed  vni\\  hot  saline  solution,  boiled  water  or  boric-acid 
solution  at  120°,  and  this  carefully  dried  out  with  gauze  mops.  Any  loops  of 
intestine  in  contact  with  the  urine  should  be  brought  out  through  the  wound, 
protected  with  hot  towels,  and  carefully  cleansed  with  mops  of  sterile  gauze.  The 
abdominal  incision  should  he  free,  in  order  to  expose  the  rent  in  the  bladder,  which 
should  then  be  sutured  with  fine  sterilized  silk,  applied  after  the  manner  of  the 
Lembert  suture  in  intestinal  surgery.  If  the  edges  of  the  wound  are  ragged,  they 
should  be  clijiped  with  scissors  and  the  sutures  inserted  not  more  tlian  one  eighth 
of  an  inch  apart,  and  should  begin  and  end  one  fourth  of  an  inch  beyond  each 
end  of  the  rent,  in  order  to  insure  perfect  closure.  It  is  safer  in  practically  all 
eases  after  a  bladder  wound  is  closed  to  insert  a  Mikulicz  gauze  packing  or  drain, 
which  consists  in  introducing  a  piece  of  sterile  gauze,  the  size  of  an  ordinary  hand- 
kerchief, the  center  of  which  is  pushed  down  into  the  deepest  part  of  tlie  pelvis 
behind  the  bladder  in  the  form  of  a  sac  or  stocking.  Into  this  pocket  a  good-sized 
wick  of  gauze  is  carried  and  brought  out  at  the  lower  angle  of  the  abdominal  inci- 
sion. At  this  stage  of  the  operation  it  is  advisable  to  perform  a  perineal  cystotomy, 
through  which  a  drainage-tube  should  be  inserted  and  secured  in  place  to  estab- 
lish thorough  drainage  of  the  bladder.  If  the  urine  is  in  this  way  discharged,  the 
bladder  wall  will  unite  readily.  The  abdominal  wound  should  be  closed  from  above 
downward,  leaving  a  small  portion  of  the  lo^o'er  angle  open  for  the  extraction  of 
the  Mikulicz  drain.  Perineal  drainage  should  be  continued  for  about  ten  days, 
and  requires  constant  attention.  Should  the  bladder  even  partially  fill,  leakage 
would  probably  occur  with  fatal  peritonitis. 

In  those  rare  cases  where  the  perforation  is  near  the  trigonum  and  intraperi- 
toneal, it  is  advised  by  some  operators  to  distend  the  rectum  with  a  Barnes  dilator, 
in  order  to  lift  the  bladder  and  bring  the  wound  into  view. 

In  extraperitoneal  perforations  the  indications  are  to  secure  immediate  free 
drainage,  which  may  be  done  through  the  perinjEum  at  the  most  convenient  point, 
and  this,  when  necessary,  should  be  reenforced  by  suprapubic  incision  and  counter- 
drainage  from  the  prevesical  space.  Wounds  of  this  variety  close  spontaneously. 
It  is  better  to  rely  upon  the  Mikulicz  drain  than  to  stitch  the  edges  of  an  intra- 
peritoneal rent  of  the  bladder  to  the  abdominal  wound. ^ 

'  The  first  successful  operation  for  gunshot  wound  of  the  bladder  was  performed  by  Amos 
C.  Walker,  of  Fort  Worth,  Texas,  March  3,  1890.  Ten  hours  after  the  injury  from  a  38-oaliber 
pistol  ball  the  abdomen  was  opened.  The  pelvis  was  filled  with  blood  clot  and  urine.  The  bladder 
was  perforated  near  the  summit,  it  having  been  distended  with  urine  at  the  time  of  the  shooting 
and  thus  lifted  above  the  symphysis  pubis.  The  ragged  aperture  in  the  bladder  was  held  open  by 
tenacula  and  the  edges  pared  smooth.  Silk  sutures  (Lembert)  closed  the  wound.  After  careful 
peritoneal  toilet,  the  abdominal  incision  was  closed  without  drainage.  Six  hours  after  operation 
the  catheter  was  introduced  and  some  bloody  urine  removed.  This  was  repeated  in  six  hours, 
and  after  that  period  the  patient  passed  his  water  voluntarily.  The  recovery  was  perfect.  The 
only  criticism  of  this  brilliant  pioneer  work  is  that  for  the  assurance  of  safety  the  catheter  should 
have  been  used  every  three  or  four  hours  for  as  many  days. 


520  THE   BLADDER 


Cystitis 


Cystitis,  an  infectious  inflammation  of  the  urinary  bladder,  is  of  frequent 
occurrence.  It  may  be  due  to  direct  infection  from  septic  inflammation  of  the 
urethra,  as  frec|uently  occurs  in  gonorrhoea  and  after  traumatism  of  this  canal 
by  the  use  of  sounds,  or  by  the  downward  extension  of  a  pyelonephritis.  It  is 
present  in  practically  all  cases  of  tumor  or  persistent  urethral  obstruction,  paral- 
ysis of  the  bladder,  stone,  etc.  It  may  be  superficial,  involving  only  a  portion  of 
the  mucous  membrane,  or  at  times  the  entire  epithelial  lining.  Most  frequently, 
however,  the  lesion  is  limited  to  the  most  dependent  portion  of  the  organ,  the 
trigonum,  the  internal  ureteral  orifices  and  prostate,  which  is  properly  considered 
a  part  of  the  urinary  bladder.  It  may  be  interstitial,  involving  the  muscular 
coat,  and,  in  very  aggravated  forms,  it  may  invade  the  serous  coat,  producing  peri- 
cystitis and  peritonitis.  According  to  the  intensity  and  duration  of  the  inflam- 
mation, cystitis  should  be  considered  as  acute  and  chronic.  Acute  cystitis  is  most 
frequently  caused  by  the  extension  of  an  infectious  urethritis  into  this  organ  or  by 
using  an  unclean  catheter.  Vaginitis  and  severe  metritis  may  produce  cystitis 
by  direct  extension  of  the  infectious  process.  It  may  be  caused  in  rare  instances 
by  sudden  and  unguarded  exposure  to  cold  and  wet.  Certain  drugs,  as  cantharides, 
may  produce  it,  and  again  it  appears  in  connection  with  certain  exanthematous 
fevers.  In  rare  instances,  a  blow  upon  the  abdomen  immediately  above  the  pubes 
or  an  injury  in  the  perineal  or  rectal  region  will  cause  cystitis.  Chronic  inflam- 
mation is  present  as  a  rule  in  all  cases  of  neoplasm  of  the  bladder,  vesical  cal- 
culus, enlarged  prostate,  stricture  or  other  obstruction,  and  is  sometimes  due  to 
the  irritation  of  concentrated  urine.  In  tropical  countries  chronic  cystitis  is  caused 
quite  frequently  by  the  presence  of  a  parasite  {Bilharzia  hcematohia) ,  one  instance 
of  which  disease  is  elsewhere  given. 

Acute  cystitis  is  usually  temporary  and  disappears  under  proper  treatment, 
leaving  no  persistent  lesion  of  the  bladder.  The  most  common  pathological  change 
is  an  injection  of  the  blood  vessels  of  the  trigonum.  This  congestion  may  at  times 
be  so  severe  that  rupture  of  the  capillaries  takes  place,  with  hsemorrhage  into  the 
bladder.  The  mucous  membrane  is  swollen  and  cedematous,  and  the  superficial 
epithelial  cells  become  loosened  and  detached.  In  very  severe  cases  extensive 
ulceration,  and  even  sloughing  of  the  mucous  membrane,  may  be  present. 

In  the  chronic  form  of  cystitis  the  extreme  jDain  which  accompanies  acute  cys- 
titis is  usually  absent.  The  urine  becomes  thick  and  alkaline  in  reaction,  and 
flakes  of  mucus  containing  bacteria,  epithelial  cells,  pus,  and  other  debris  are 
present.  The  bacteria  convert  the  urea  into  carbonate  of  ammonia,  producing  the 
well-known  ammoniacal  decomposition  of  the  urine,  which  intensifies  the  inflam- 
mation. The  bladder  wall  itself  becomes  thickened.  The  normal  folds  or  rugw 
are  hypertrophied.  The  thickening  may  be  caused  by  an  increase  of  the  muscular 
elements.  There  is  usually,  however,  atrophy  of  these  elements  with  a  hypertrophy 
of  the  connective  tissues,  in  which  the  cavity  of  the  bladder  is  lessened,  concentric 
hypertrophy.  When  the  cavity  is  increased  and  the  walls  thickened,  it  is  called 
eccentric  hypertrophy. 

Causes. — Directly  or  indirectly,  gonorrha?a  may  stand  as  the  chief  cause. 
Stricture  of  the  urethra,  especially  in  the  membranous  portion,  enlarged  prostate 
{in  which  case  it  is  more  often  the  result  of  catheterization  than  of  the  actual 
obstruction) ,  calculus,  vesical  tumors,  paralysis  with  decomposition  of  urine,  gout, 
and  rheumatism  are  other  causes.  An  attack  is  precipitated  by  exposure  to  cold 
and  wet,  and  pyelitis  and  pyelonephritis  are  nearly,  always  accompanied  by  inflam- 
mation of  the  bladder. 

Symptoms. — The  most  prominent  symptom  of  acute  cystitis  is  a  constant  desire 
to  micturate  with  the  passage  of  only  a  few  drops  of  urine,  accompanied  by  pain, 
burning,  and  straining  (tenesmus).  The  pain  may  extend  to  the  periuEeum  or 
above  the  pubes,  radiate  down  the  inner  side  of  the  thighs,  or  to  the  sacral  region. 
Again,  there  may  be  pain  at  the  head  of  the  penis.  The  pain  is  increased  at  the 
close  of  the  attempt  to  urinate,  and  reaches  its  intensity  as  the  last  few  drops  are 
forced  out.     The  diagnosis  is  clear  when  frequent  micturition,  pain,  and  pus  in 


THE   BLADDER 


521 


the  urine  are  present.  If  there  be  rupture  in  the  capillaries  due  to  intense  con- 
gestion, blood  will  be  present  in  the  urine,  although  it  is  only  in  severe  cases  that 
this  is  found,  and  its  presence  is  usually  discovered  only  iDy  the  microscope.  The 
urine,  as  a  rule,  is  neutral  or  alkaline  in  reaction,  with  a  distinctly  foul  odor,  and 
always  contains  albumin  due  to  pus. 

Microscopical  examination  of  the  urine  is  of  great  value  in  making  the  diag- 
nosis and  should  always  be  employed.  There  may  be  fever  or  not.  In  mild  cases 
there  are  no  symptoms  other  than  those  referable  to  the  bladder.  In  severe  cases 
constitutional  symptoms,  such  as  chills  and  high  temperature,  may  be  present. 

In  chronic  cystitis  all  of  the  symptoms  described  in  the  acute  form  are  les- 
sened; pain  may  be  slight  or  entirely  absent,  but  the  urine  is  always  thick  and 
foetid. 

Treatment. — In  acute  cystitis  it  is  of  first  importance  to  secure  perfect  rest  in 
bed  in  that  position  which  gives  the  least  sense  of  discomfort.  As  the  inflamma- 
tion is  usually  confined  to  the  most  dependent  portion  of  the  organ,  the  trigonum 
and  the  prostatic  urethra,  it  is  advisable  to  elevate  the  foot  of  the  bed  and  place 
a  pillow  under  the  patient's  hips.  By  these  means  pressure  upon  the  irritated 
viscus  by  the  intestines,  which  usually  rest  upon  it.  is  relieved,  ilorphia  for  the 
alleviation  of  pain  and  the  enforcement  of  rest  are  necessary.  Hot  or  cold  applica- 
tions, as  found  most  agreeable  to  the  patient,  should  be  employed.  The  use  of 
morphia  per  os  or  hypodermically,  in  my  opinion,  is  preferable  to  suppositories, 
which  must,  of  necessity,  produce  a  certain  amount  of  irritation  when  they  are 
inserted  so  near  a  diseased  organ.  The  rectum  should  be  carefully  emptied  by  a 
warm  enema  or  by  the  administration  of  calomel  triturates.  The  free  adminis- 
tration of  water — preferably  alkaline  waters,  such  as  Yichy — and  citrate  of  potas- 
sium in  twenty-grain  doses  are  advised.  In  both  the  acute  and  chronic  forms  of 
the  disease  it  is  essential  to  eliminate  all  alcoholic  drinks. 

In  chronic  cystitis,  treatment  should  be  directed  first  to  the  cause  of  the  in- 
flammation. When  resulting  from  the  presence  of  a  stone  or  tumor  of  the  blad- 
der or  prostate,  from  retention  by  stricture  or  any  other  obstruction,  causing 
ammoniacal  decomposition  and  a  general  cystitis,  removal  of  the  stone  or  tumor 


Fig.  526. — Nelaton's  catheter. 


and  of  the  obstruction  is  imperative.  Cystitis  resulting  from  pj^elitis  cannot  be 
cured  unless  the  pyelitis  is  first  relieved.  In  certain  forms  of  retention  resulting 
from  paralysis  or  atony  of  the  muscular  walls  of  the  bladder,  the  retention  may 
be  relieved  by  the  emploj-ment  of  the  soft  catheter,  and  the  condition  of  the  organ 
temporarily  relieved  by  irrigation.  The  soft- rubber  catheter  of  Xelaton  (Fig. 
526)    produces  less  irritation  than   the  harder   instruments,   and  should  be  pre- 


FiG.   527. — ^'eh'et-eved  ; 


atheters,  cur\-ed  and  straight. 


ferred.  An  instriunent  of  good  size.  Xos.  12  to  14.  United  States  scale,  with  a 
perfectly  smooth  point  should  be  selected.  It  should  be  perfectly  sterile,  warm, 
lubricated  with  sterile  sweet  oil  or  glycerine,  and  introduced  with  the  patient  rest- 
ing on  the  back.     An  effort  should  be  made  to  carry  the  eye  of  the  instrument 


522 


THE   BLADDER 


just  deep  enough  to  project  well  into  the  bladder  without  touching  the  posterior 
wall.  The  double-current  soft  catheter  (Fig.  528)  is  a  useful  instrument  for 
bladder  irrio-ation,  but  is  not  necessary  for  successful  treatment.  Its  objections 
are  that  it  is  costly  and  more  difficult  to  keep  thoroughly  sterile  than  the  simpler 
instrument.  The  advantage  it  possesses  is  that  the  inflow  and  outflow  is  constant. 
The  ordinary  simple  catheter  will,  however,  answer  every  purpose.  It  is  important 
to  prevent  the  admission  of  air  into  the  bladder  by  filling  the  catheter  with  the 


Fig.  528. — Double-current  soft  catheter,  for  irrigating  the  bladder. 


fluid  to  be  injected  when  the  eye  of  the  instrument  is  passed  to  the  cut-off  muscle. 
If  the  bladder  should  be  partially  filled  with  urine  at  the  time  of  introduction, 
the  air  which  is  in  the  instrument  will  be  forced  out  immediately  by  the  outflow 
of  urine.  For  the  purposes  of  irrigation,  a  warm  solution  of  permanganate  of 
potassium,  1-5000  (three  grains  to  the  quart)  is  employed,  and  next  in  order  a 
solution  of  boric  acid,  one  dram  to  the  pint,  and,  when  these  are  not  convenient, 
clean  water  which  has  been  boiled  and  allowed  to  cool  down  to  a  temperature  of 
100°  to  105°  F.  may  be  used.  Several  pints  of  the  irrigating  fluid  are  placed 
in  a  foimtain  syringe,  a  small  quantity  is  allowed  to  run  through  the  nozzle  to 
displace  the  air,  the  point  of  the  nozzle  is  then  introduced  on  the  end  of  the 
catheter  and  the  irrigating  fluid  allowed  to  run  in  slowly,  and  the  bladder  dis- 
tended to  the  point  of  tolerance.  It  is  then  allowed  to  empty  itself  through  the 
catheter,  and  this  is  repeated  until  the  fluid  which  escapes  is  clear.  These  irri- 
gations may  be  repeated  once  or  twice  weekly  if  necessary. 

A  simpler  method  of  irrigation  of  the  bladder  which  obviates  the  use  of  the 
catheter  is  as  follows :  The  nozzle  of  the  irrigator  should  be  carried  into  the  meatus 
and  the  anterior  urethra  flushed  out  in  order  to  render  it  aseptic.  Then  by  firmer 
pressure  of  the  nozzle  at  the  meatus,  the  urethra  is  gradually  distended  by  hydro- 
static pressure,  and  in  the  course  of  a  minute  or  more  the  cut-off  muscle  gives  way 


.;'^-^^^ 


Fig.  529. — Filiform  catheter. 

and  the  fluid  runs  readily  into  the  bladder.  If  there  is  marked  resistance  due  to 
spasm  of  the  compressor  urethrse,  if  the  patient  is  advised  to  attempt  to  empty 
his  bladder,  this  muscle  immediately  gives  way  and  the  water  flows  back  into  the 
bladder.  As  soon  as  it  is  sufficiently  distended,  the  patient  is  allowed  to  evacuate 
the  injected  fluid  and  the  operation  is  repeated  until  the  fluid  returns  clear. 

In  cases  that  resist  all  conservative  measures,  incision  with  drainage,  preferably 
by  the  suprapubic  method  (or  through  the  perinseum,  as  in  the  median  operation 
for  stone)   is  imperative. 

My  clinical  notes  contain  twenty  cases  of  suprapubic  cystotomy  for  chronic 
cystitis  uncomplicated  by  tumor  or  stone.  This  condition  existed  in  all  the  cases 
of  stone  and  tumor,  making  twenty-nine  additional,  or  a  total  of  forty-nine  cases 
operated  upon  in  which  chronic  cystitis  existed.  The  shortest  period  of  drainage 
was  seventeen  days;  the  longest,  eight  weeks.     In  twelve  of  the  twenty  cases  of 


THE   BLADDER 


523 


drainage  in  uncomplicated  cystitis  a  cure  resulted ;  two  others  were  improved,  and 
in  one  permanent  drainage  was  established  on  account  of  paralysis  of  the  bladder; 
one  case  was  not  benefited  by  the  operation. 

Paralysis  of  the  bladder  may  be  partial  or  complete.  It  may  be  caused  by  vio- 
lence inflicted  directly  to  the  organ  or  in  its  immediate  neighborhood,  by  patho- 
logical changes  in  its  muscular  tissue,  or  lay  traumatic  or  idiopathic  lesions  of  the 
cerebro-spinal  axis;  or  it  may  occur  under  the  influence  of  certain  emotions  in 
which  no  lesion  is  recognizable. 

The  prolonged  overdistention  of  the  organ  which  is  common  in  prostatic  hyper- 
trophy will  induce  the  same  condition. 

In  the  treatment  of  this  affection  the  first^  indication  is  to  prevent  prolonged 
distention  of  the  organ  by  catheterization,  which  should  be  repeated  at  least  twice 
in  twenty-four  hours.     If  a  catheter  cannot  he  introduced,  suprapubic  aspiration 


Fig.   5.30.^r.lark  li 


i.-tiT,  lihmt-pointed. 


should  be  practiced.  Cystitis  may  be  avoided  if  the  urine  is  carefully  and  regu- 
larly drawn  ofl:  with  careful  antiseptic  precautions.  Attention  should  next  be 
directed  to  the  removal  of  the  cause  of  the  paralysis.  If  the  paresis  is  permanent, 
suprapubic  drainage  is  advisable. 

Retention. — As  just  stated,  paralysis  of  the  muscular  walls  of  the  bladder  is  a 
cause  of  retention  of  urine.  Lesions  of  the  sensory  nerves  of  this  organ  also  induce 
retention,  which  is  proportionate  to  the  loss  of  sensibility.     The  chief  cause,  how- 


FiG.   531. — Black  French  catheter,  ohve-pointed.  * 

ever,  is  some  form  of  obstruction  at  the  neck  of  the  bladder  or  in  the  urethra. 
As  will  be  seen  in  treating  of  hypertrophy  of  the  prostate,  this  is  a  frequent  cause 
of  retention.  Organic  stricture,  spasm  of  the  compressor  urethras  (or  "  cut-off  ") 
muscle,  and  mechanical  occlusion  of  the  urethra,  are  also  common  causes  of  this 
affection. 

Diagnosis. — Distention  of  the  bladder  may  be  determined  by  palpation,  per- 
cussion, and  exploration.     In  this  condition  it  rises  well  above  the  level  of  the 


Fig.  532. — Gummed  silk-woven  catheter. 

symphysis  pubis,  at  times  as  high  ^as  the  umbilicus,  and  causes  tension  of  the 
recti  muscles  or  protrusion  of  the  abclomen.  In  one  instance  I  drew  off  sis  quarts 
of  urine.  By  direct  pressure,  the  desire  on  the  part  of  the  patient  to.  urinate  may 
usually  be  increased,  and,  if  the  abdominal  walls  are  thin,  the  spherical  character 
of  the  organ  may  be  recognized. 

In  treatment,  the  evacuation  of  the  contents  is  the  immediate  indication.     The 
patient  should  be  put  to  l)ed  and  given  the  benefit  of  a  full  dose  of  opium.     This 


I'^rc.   533. — Gummed  silk-woven  boug 


agent  is  useful  in  alleviating  pain,  in  securing  relaxation  of  the  muscular  elements 
of  the  urethra  and  prostate,  and — lay  producing  diaphoresis — in  diverting  fluids 
from  the  kidneys  to  the  excretory  apparatus  of  the  skin.     A  soft-rubber  (ISfelaton) 


524  THE   BLADDER 

catheter  should  be  preferred;  but,  if  this  cannot  be  introduced,  a  firmer,  olive- 
pointed  instrument  (Fig.  531)  should  be  employed.  The  silk-woven  and  gummed 
catheter  (Figs.  532  and  533)  is  also  a  useful  instrument,  and  if,  on  account  of 
its  elasticity,  it  cannot  be  introduced,  the  stylet  of  Professor  Keyes  (Fig.  534) 
should  be  inserted  into  the  catheter  to  give  it  the  required  stiffness.     The  metal 


(LTIEMANH  &C0. 

Fig.   534. — Dr.  Keyes'  wire  stylet. 


-o 


catheter  (Fig.  535),  if  properly  constructed  and  carefully  introduced,  can  be 
made  to  safely  overcome  any  ordinary  resistance.  It  should  be  of  heavy  silver, 
strong,  perfectly  smooth,  and  should  have  a  curve  corresponding  to  that  of  the 
normal  urethra.  In  size  it  should  correspond  to  No.  10,  12,  or  14,  U.  S.,  and  the 
larger  sizes  should  be  preferred. 


Fig.  535. — ^Strong  silver  catheter. 


The  introd\;ction  of  a  metal  catheter  or  sound  through  the  normal  urethra  into 
the  bladder  is  accomplished  as  follows:  The  patient  is  placed  upon  the  back  with 
the  lower  extremities  parallel  with  the  body.  If  about  oj  to  oij  of  a  two-per-cent 
solution  of  cocaine  hydrochlorate  is  introduced,  the  normal  sensibility  will  be 
lost  as  far  back  as  the  coiupressor  muscle.  The  urethra  is  then  flushed  with  warm 
boric-acid  or  permanganate-of-potash  solution.  The  catheter  is  placed  in  water 
at  a  temperature  of  about  105°  to  110°  F.,  and,  when  warmed  through,  is  lubri- 
cated with  sterilized  sweet  oil  or  glycerine.  If  the  operator  is  right-handed,  it  is 
best  to  stand  on  the  left  side  of  and  facing  the  patient.  The  penis  is  seized  with 
the  left  hand  and  held  steady  while  the  end  of  the  catheter  is  carried  into  the 
meatus.  At  this  stage  of  the  procedure  the  shaft  of  the  sound  is  parallel  with 
Poupart's  ligament,  and,  as  soon  as  the  first  four  inches  have  passed  into  the 
urethra,  while  it  still  descends,  the  handle  is  gradually  brought  toward  the  median 
line.  The  point  is  now  engaged  in  the  bulb,  or  at  the  anterior  layer  of  the  trian- 
gular ligament,  and  the  shaft  is  about  perpendicular  to  the  plane  of  the  abdomen. 
Without  exercising  any  force  to  push  the  instrument  in  the  direction  of  the  blad- 
der, the  handle  is  slowly  and  steadily  carried  downward  until  the  shaft  is  parallel 
with  the  anterior  surface  of  the  thighs.  While  this  manoeuvre  is  being  efEected, 
the  point  is  tilted  from  the  floor  of  the  bulb  into  the  membranous  portion  which 
offers  the  greatest  resistance,  not  only  because  it  is  the  narrowest  part  of  the  canal, 
but  because  the  compressor-urethras  muscle  must  be  overcome.  All  the  time  that 
the  instrument  is  being  pushed  toward  the  bladder  the  penis  should  be  pulled 
over  the  catheter,  for  in  this  way  the  lining  membrane  is  put  upon  the  stretch  ' 
and  the  introduction  greatly  facilitated.  When  the  neck  of  the  bladder  is  reached, 
the  instrument  will  usually  have  penetrated  a  distance  of  eight  or  nine  inches. 
It  should  be  borne  in  mind  that  even  a  silver  catheter  is  capable  of  doing  damage 
to  the  urethra  if  improper  force  is  employed  in  its  introduction.  There  is  usually 
no  resistance  except  by  the  compressor  muscle,  and  this  is  only  spasmodic.  If 
the  point  of  the  instrument  is  kept  well  against  this  obstruction  by  depressing  the 
handle  between  the  thighs,  it  will  slip  by  "with  the  first  relaxation  of  this  muscle. 
The  methods  of  introducing  an  instrument  into  the  bladder  in  abnormal  condi- 
tions of  the  urethra  and  prostate  will  be  given  later. 

If  it  is  found  impossible  to  reach  the  bladder  by  the  urethra,  the  urine  should 
be  evacuated  by  the  aspirator.  The  apparatus  shown  in  Fig.  536  will  give  general 
satisfaction.  The  needle  should  be  carefully  cleansed  by  "boiling.  The  medium 
or  smallest  needle  will  suffice.     If  its  introduction  is  preceded  by  a  small  hypo- 


THE   BL.U)DER 


525 


dermic  sjTinge  needle,  and  TT[,x  of  four-per-eent  cocaine  are  injected,  the  operation 
•will  be  painless.  The  pubes  being  shaved  and  disinfected,  and  everything  in  readi- 
ness, the  cock  (6',  Fig.  .536)  is  closed;  the  air  is  exhausted  from  the  receiver  (2)  by 

working  the  pump  (4)-  The  patient 
shoidd  be  placed  in  the  sitting  posture, 
and  the  needle  introduced  a  half  inch 
above  the  symphysis  and  pushed  directly 
backward  a  distance  of  two  inches.  The 
cock  is  now  opened,  and  the  urine  flows 
into  the  bottle.  If  it  becomes  necessary 
to  empty  the  receiver,  the  stopcock  should 
be  turned,  to  prevent  the  entrance  of  air 
into  the  bladder.  When  the  aspirator 
is  not  convenient  the  small  trocar  and 
canula  may  be  introduced.  The  danger 
of  leakage  at  the  point  of  puncture  is 
insisrnifieant. 


Fig.  536. — Tiemann  &  Co.'s  aspirator. 


-Female  and  male  urinals,  for 
tinence. 


When  the  character  of  the  obstruction  or  disease  is  such  that  a  permanent  uri- 
nary fistula  is  necessarv,  suprapubic  cystotomy  is  advised. 

Incontinence  of  Urine. — Incontinence  of  urine  occurs  when  the  compressor 
urethrffi  is  partially  or  completely  paralyzed.  It  is  also  present  in  a  proportion 
of  cases  of  prolonged  overdistention  of  the  bladder  (overflow),  the  pressure  from 
behind  overcoming  the  normal  resistance  of  these  muscles.  Irritation  of  the  blad- 
der from  any  cause  may  produce  tenesmus  of  this  organ,  and  consequent  inability 
to  retain  the  urine.  This  is  especially  apt  to  occur  in  children  during  sleep,  in 
the  earlier  hours  of  morning,  when  the  bladder  is  full. 

Women  are  more  frequently  affected  with  incontinence  than  men,  which  fact 
is  explained  not  only  in  the  better  tone  of  the  muscular  system  in  males,  but  in 
the  absence  of  the  prostatic  muscle  in  females,  which,  according  to  Henle.  is  of 
great  aid  in  holding  the  urethra  closed.  The  general  relaxation  of  the  pelvic  mus- 
cles as  a  result  of  parturition  may  also  account  for  the  more  frequent  occurrence 
of  incontinence  of  urine  in  women. 

The  palliative  treatment  consists  in.  applying  a  urinal  for  the  reception  of  the 
water  as  it  dribbles  away  (Fig.  537). 

Curative  measures  shotdd  be  directed  to  a  removal  of  the  cause  of  inconti- 
nence. These  will  be  given  with  the  various  lesions  of  which  it  is  a  s^-mptom. 
In  the  nocturnal  incontinence  of  children  the  habit  may  be  corrected  by  causing 
the  patient  to  be  awakened  and  the  bladder  emptied  once  or  twice  during  the 
night. 

Dr.  H.  Clarion-Sims  reported  to  the  Xew  York  Obstetrical  Society  a  ntimber 
of  distressincf  cases  of  incontinence  of  urine  in  adult  females.     These  cases  were 


526  THE   BLADDER 

cured  by  o-radual  and  frequently  repeated  distention  of  the  bladder.  His  method 
was  to  introduce,  by  means  of  a  Davidson  syringe  through  a  catheter,  cold  or  tepid 
water  beginning  with  gj,  holding  this  in  for  some  minutes  and  then  allowing  it 
to  be  evacuated.  The  next  day  an  ounce  and  a  half  was  injected,  and  this  was 
continued  until  one  pint  or  more  was  easily  contained.  In  this  manner  tolerance 
was  established  and  a  cure  effected. 

Suppression  of  Urine. — Not  infrequently  after  prolonged  operations  under 
ether  or  chloroform  narcosis,  and  especially  on  patients  the  subject  of  nephritis, 
the  function  of  the  kidneys  is  partially  or  completely  suspended.  Suppression 
may  also  follow  an  injury  of  any  part  of  the  body  and  as  a  result  of  any  strong 
emotion.  It  may  occur  in  subjects  with  no  recognizable  lesion  of  the  kidneys,  but, 
as  said  before,  is  especially  liable  to  occur  where  these  organs  are  diseased.  The 
skin  is  usually  hot  and  dry,  the  pulse  rapid  and  full,  there  is  great  restlessness 
and  anxiety,  and  the  temperature  is  elevated  several  degrees  above  normal.  The 
diagnosis  may  be  confirmed  by  the  introduction  of  the  catheter,  when  the  blad- 
der will  be  found  to  be  contracted  and  empty,  or  containing  only  a  small  quantity 
of  urine.  Suppression  of  urine  is  an  extremely  dangerous  condition,  and,  if  not 
relieved,  rapidly  induces  ursemic  coma  and  death.  The  best  method  of  treatment 
is  believed  to  be  the  intravenous  injection  of  hot  salt  solution  in  the  same  manner 
as  described  in  the  article  on  transfusion.  From  one  to  two  pints  may  be  injected. 
The  continuous  influx  of  salt  solution,  as  practiced  by  J.  B.  Murphy  in  the  treat- 
ment of  diffuse  peritonitis,  is  advised  when  urtemia  is  imminent.  In  milder  cases 
the  urinary  function  may  be  restored  by  the  hypodermic  injection  of  morphia 
and  of  digitalis  in  the  form  of  digitalin,  reenforced  by  warm  drinks  and  external 
applications  to  promote  diaphoresis. 

Neoplasms  of  the  Bladder. — New  growths  of  the  bladder  are  classified  accord- 
ing to  the  tissues  from  which  they  have  their  origin  or  of  which  they  are  composed.^ 
In  the  epithelial  group  a;re  papilloma,  adenoma,  carcinoma,  and  cysts.  The  con- 
nective-tissue groups  are  fibroma,  myxoma,  and  sarcoma;  the  muscle  group,  my- 
oma. A  fourth  or  heterotopic  group  in  which  the  tumor  does  not  originate  from 
the  normal  elements  of  the  bladder  wall  has  been  suggested  to  include  chondro- 
myoma,  rhabdomyoma,  and  dermoid,  also  adeno-carcinoma,  myo-  or  myxo-sarcoma, 
when  more  than  one  variety  of  tissues  are  involved  may  be  found. 

The  vast  majority  of  neoplasms  of  the  bladder  occur  in  males  (about  ninety 
per  cent),  and  the  larger  proportion  are  malignant.  These  may  remain  localized 
and  practically  unobserved  for  a  very  considerable  period.  Primary  tumors  of 
the  bladder  comprise  less  than  one  per  cent  of  all  new  growths.  The  extension 
of  the  tumor  to  the  bladder  from  a  contiguous  organ — the  prostate,  rectum,  uterus, 
vagina,  etc. — is  not  the  rule,  and  tumors  of  the  bladder  by  general  metastasis  are 
exceedingly  rare. 

While  benign  tumors  may  occur  in  any  period  of  life,  the  malignant  tumors, 
especially  carcinoma,  are  most  frequently  observed  between  the  fiftieth  and  sixtieth 
years  of  life. 

Sarcoma,  as  is  well  known,  occurs  in  old  or  young  subjects,  and  may  even  be 
met  with  in  very  young  children. 

Papilloma,  or  more  properly  papillary  fiiro-epitlielioma,  may  occur  single  or 
multiple,  and  may  spring  from  any  portion  of  the  bladder  wall.  The  typical  form 
has  a  stem,  or  mushroom-like  pedicle,  springing  directly  from  the  mucosa,  from 
the  extremity  or  stump  of  which  tufts  of  villi  crop  out,  resembling  in  miniature 
a  box  shrub.  When  these  spring  from  the  trigone  the  pedicle  is  more  closely  at- 
tached to  the  submucous  connective  tissue,  while  on  other  portions  of  the  bladder 
the  attachment  is  less  and  the  tumor  more  readily  extirpated.  From  this  it  is 
evident  that  in  the  removal  of  a  papilloma  from  the  trigone  very  considerable  care 
is  necessary  to  destroy  by  cauterization  the  connections  in  the  deep  attachments 
.  in  the  submucous  connective  tissue. 

'  For  this  classification  and  the  pathology  which  follows,  the  author  is  especially  indebted  to  a 
very  instructive  paper  read  before  the  New  York  Academy  of  Medicine,  1907,  by  Dr.  F.  S.  Mandle- 
baum,  Pathologist  to  Mt.  Sinai  Hospital,  and  later  published  in  "Surg.,  Gyn.  and  Obstetrics," 
September,  1907. 


THE   BLADDER  527 

Occasionally  these  papillomata  are  sessile  or  nodular  in  shape,  and  contain 
an  unusual  quantity  of  fibrous  connective  tissue. 

The  softer  or  villous  forms  of  papillomata  at  times  occur  with  great  rapidity, 
and  may  iill  the  entire  bladder.  They  tend  to  recur  after  removal,  and  may 
appear  in  benign  form  or  distinctly  malignant.  When  the  malignant  transforma- 
tion occurs  it  is  first  seen  either  in  the  deeper  portions,  or  in  the  lovs^er  layers  of 
epithelium  of  the  villi. 

A  papillary  carcinoma  resembles  a  simple  papilloma  so  closely  that  the  micro- 
scope alone  can  differentiate.  In  the  malignant  form  the  epithelial  cells  lose  the 
typical  arrangement  of  papilloma,  are  polymorphous  in  character,  showing  an 
infiltration  of  the  stroma. 

Carcinoma  of  the  bladder  which  is  not  of  papillomatous  origin  is  comparatively 
rare.  There  is  sometimes  observed  a  flat  or  squamous-cell  carcinoma,  which,  break- 
ing down,  may  appear  in  the  form  of  an  ulcer.  Of  this  type  Mandlebaum  reports 
only  two  cases.  The  squamous  carcinoma  may  be  hard  or  soft,  and  in  very  rare 
instances  the  squamous  and  cylindrical  cells  are  found  side  by  side  in  the  same 
neoplasm. 

Fihro-carcinoma  also  occurs  in  this  organ.  Mandlebaum  reports  five  cases  oc- 
curring between  the  ages  of  fifty- two  and  sixty-five  years,  with  infiltration  of  the 
bladder  wall  in  each  case.  All  terminated  fatally.  These  tumors,  which  are 
hard  and  dense  in  structure,  are  confined  mostly  to  the  region  of  the  trigone. 
This  observer  emphasizes  the  fact  that  almost  all  of  the  fibro-carcinomata  (medul- 
lary or  scirrhus  malignant  tumors)  occur  secondarily  by  direct  extension  from 
primary  growths  of  the  prostate.  A  knowledge  of  this  fact  suggests  early  opera- 
tion upon  the  prostate  in  all  cases  of  rapidly  growing  tumor  of  this  organ. 

Adeno-carcinoma  may  be  found  in  the  bladder.  This  type  is  infrequent  and 
may  also  arise  as  a  primary  growth  of  the  prostate.  Mandlebaum's  two  cases  were 
of  this  nature,  and  both  ended  fatally. 

Simple  adenoma  and  fibro-adenoma  are  quite  rare  in  the  bladder,  and  in  all 
prohability  the  latter  form  is  always  secondary  to  prostatic  neoplasm. 

Colloid  carcinoma  of  the  bladder  is  not  common,  and  is  supposed  to  originate 
from  epithelial  degeneration  of  the  glandular  tissues  associated  with  the  bladder 
mucosa,  forming  colloid  cysts  from  which  a  carcinoma  may  arise. 

Cysts  other  than  those  arising  from  the  glands  of  Limbeck  are  sometimes  found 
resulting  from  congenital  defects  of  the  urachus.  Wolffian  body,  or  Gartner's  duct. 
This  form  of  tumor  is  fortunately  very  exceptional. 

The  connective-tissue  tumors  are  less  frequent  than  those  just  described.  The 
most  usual  form,  fibroma,  is  met  with  usually  at  the  base  of  the  bladder  where 
it  develops  beneath  the  mucosa. 

Myxoma  is  of  more  frequent  occurrence,  especially  in  childhood.  It  may 
occur  as  a  simple  pedunculated  polypoid  growth,  or  as  multiple,  rapidly  growing 
nodules,  having  a  marked  tendency  to  recur  after  removal  (Mandlebaum).  His- 
tologically it  shows  branching  cells  and  mucous  tissue,  and  is  very  vascular,  the 
surface  being  usually  covered  with  a  seemingly  normal  mucous  membrane.  Its 
favorite  site  is  near  the  urethral  opening. 

Myxosarcoma  may  develop  from  or  be  associated  with  this  form  of  tumor. 

Other  sarcomata  occurring  in  the  bladder'  may  be  single  or  multiple,  hard  or 
soft.    As  a  rule  they  are  sessile  in  shape,  at  times  pedunculated. 

Myomata  of  the  bladder  are  rare.  They  spring  directly  from  the  muscle  fibers, 
either  as  single  or  multiple  growths.  As  a  rule  they  are  covered  with  mucosa  and 
are  nodular  in  shape.  It  is  almost  always  composed  of  unstriped  muscle,  but  in 
exceptional  instances  the  striated  variety   (rhabdomyoma)   has  been  observed. 

Dermoid  of  the  bladder  has  been  reported  in  only  a  single  instance. 

The  diagnosis  of  the  presence  of  tumor  may  be  evident  from  symptoms  of  pres- 
sure, interference  with  urination,  from  bloody  urine,  from  the  microscopical  ex- 
amination of  shreds  of  tissue  discharged,  by  manual  examination,  and  by  the  use 
of  the  cystoscope  or  sound.  Under  certain  conditions  where  a  tumor  is  suspected, 
such  is  the  importance  of  its  early  recognition  that  a  suprapubic  cystotomy  should 
be  performed.     This  operation  is  especially  commended  in  view  of  the  fact  that 


528  THE   BLADDER 

it  is  practically  without  danger,  and  can  be  done  for  purposes  of  exploration  with 
cocaine  infiltration.  The  diflerentiation  from  the  tumor  of  the  prostate,  or  the 
recognition  of  a  tumor  partly  prostatic  and  j)artly  vesicular,  may  be  at  times  deter- 
mined, in  the  male  by  rectal,  in  the  female  by  vaginal  exploration  with  firm  pres- 
sure above  the  pubis,  with  complete  relaxation  of  the  abdominal  muscle. 

Treatment. — Neoplasms  of  the  bladder  or  prostate  should  be  removed  by  oi^era- 
tion  at  the  earliest  possible  moment.  When  they  are  connected  entirely  with  the 
bladder  the  route  is  by  the  suprapubic  method.  If  they  are  intimately  associated 
with  the  prostate  and  the  neck  or  base  of  the  bladder,  the  perineal  route  may  also 
be  combined  with  the  suprapubic.  In  the  operation  for  the  removal  of  a  tumor 
of  the  bladder  the  importance  of  a  free  opening  in  this  organ  should  be  borne  in 
mind.  The  perpendicular  incision  in  the  median  line  should  extend  from  below 
the  level  of  the  pubes  at  the  symphysis  at  least  as  high  as  the  peritoneal  attach- 
ment, and  should  emergency  demand,  it  should  extend  to  the  umbilicus  or  higher. 
The  sheath  of  the  rectus  of  either  side  may  be  divided  for  one  half  inch  in  a  trans- 
verse direction,  when  it  becomes  absolutely  necessary  to  have  a  wider  opening. 
This  transverse  part  of  the  incision  should  be  closed  with  kangaroo  tendon  sutures 
to  prevent  a  possible  hernia.  It  is  almost  always  advisable  to  dissect  the  peri- 
tonffium  from  the  summit  of  the  bladder  for  one"  or  two  inches  or  farther  in 
order  to  permit  of  a  free  inspection.  This  is  not  difficult  when  the  bladder  has 
been  filled  with  twelve  to  eighteen  ounces'  of  normal  salt  solution.  Should  an 
opening  be  torn  into  the  peritonasum,  this  may  be  closed,  or  a  careful  walling  ofE 
of  the  peritoneal  cavity  by  gauze  mats  taken  from  hot  salt  solution  may  be  done. 
Before  incising  the  bladder  two  or  three  silk  or  linen  loop  sutures  should  be  carried 
entirely  through  the  walls  of  this  organ  on  either  side  of  the  proposed  line  of 
incision.  This  can  readily  be  done  by  using  two  full-curved  Hagedorn  needles. 
By  having  two  needles  threaded  and  inserting  them  rapidly,  a  very  small  part  of 
the  water  in  the  bladder  will  escape  through  the  puncture  before  the  incision  can 
be  made.  While  the  bladder  is  being  firmly  held  against  the  abdominal  wall  by 
retraction  on  these  loops,  the  incision  is  made  by  inserting  the  knife  at  the  level 
of  the  pubis  and  cutting  quickly  upward  in  the  middle  line  in  the  direction  of 
the  linea  alba.  Not  infrequently  one  or  two  large  veins  are  distributed  to  the 
anterior  surface  of  this  organ,  and  these  can  be  avoided  in  the  section.  Should 
it  be  necessary  to  prevent  loosening  the  anterior  wall  of  the  bladder  from  the  ab- 
dominal wall,  two  or  three  additional  supporting  loop  sutures  should  be  inserted. 
The  retractors  are  now  inserted,  and  the  internal  surface  of  the  bladder  carefully 
examined.  In  order  to  prevent  too  great  collapse  of  the  bladder  when  it  is  incised 
and  the  salt  solution  escapes,  flat  retractors  shaped  like  a  fish  hook  have  been 
devised,  and  are  very  serviceable.  The  tumor  should  be  carefully  removed,  the 
mucous  membrane  being  clipped  ofE  with  the  pedicle  or  base,  and  an  application 
of  a  few  drops  of  pure  carbolic  acid  upon  a  tuft  of  gauze  made  to  the  wound  from 
which  the  pedicle  was  removed.  If  the  tumor  is  partly  prostatic,  the  perineal 
incision  and  the  operative  method  which  will  be  given  in  connection  with  prostatec- 
tomy is  advised.  The  after-treatment  will  depend  in  large  measure  upon  the  size 
and  character  of  the  neo|)lasm  removed.  For  a  small  papilloma,  the  bladder  being 
in  fairly  good  condition,  the  bladder  wound  may  be  cleansed  at  once  by  a  run- 
ning or  interrupted  suture  of  No.  '3  chromicized  catgut,  leaving  the  abdominal 
incision  at  the  lower  angle  open  for  the  distance  of  an  inch,  in  case  there  should 
occur  a  leakage.  A  small  bit  of  sterile  gauze  loosely  packed  into  this  wound  will 
suffice.  The  introduction  of  the  catheter  every  four  hours  for  the  first  twenty- 
four  hours,  and  every  six  hours  after  this,  will  suffice  to  keep  the  strain  of  over- 
distention  from  the  sutures.  Should  the  neoplasm  prove  to  be  a  sarcoma,  the 
use  of  the  mixed  toxines  should  be  urged. 

The  Urine. — The  average  quantity  of  urine  excreted  in  twentj'-four  hours  is 
fifty-six  ounces.  This  quantity  varies  with  the  amount  of  fluids  ingested,  the 
non-activity  of  the  sweat  glands,  etc.  Certain  conditions  of  the  nervous  system 
— diabetes,  chronic  interstitial  nephritis,  chronic  diffuse  nephritis,  and  amyloid 
infiltration  will  increase  the  quantity. 

The  urine  will  be  diminished  when  a  small  quantity  of  liquid  is  taken,  by 


THE   BLADDER  529 

free  perspiration,  fever,  diarrhoea,  vomiting,  the  early  stages  of  acute  diffuse 
nephritis,  subacute  glomerular  nepluitis,  and  toward  death  in  all  diseases 
(Ogden). 

The  normal  specific  gravity  varies  from  1.015  to  1.020,  but  even  under  condi- 
tions of  health  the  range  may  be  from  1.002  to  1.040.  Usually  the  increase  in 
cjiTantity  is  accompanied  by  a  smaller  proportion  of  solids  and  a  consequent  lower 
specific  gra-^dty.  This  is  not  the  case  in  diabetes,  where  the  quantity  is  abnormally 
large  while  the  urinometer  may  vary  from  1.030  to  1.040. 

The  color  of  urine  is  amber  or  straw-color,  due  to  the  presence  of  indiean,  uro- 
biline,  etc.  It  is  dark  in  f)roportion  to  the  intensity  of  the  destructive  changes  in 
the  tissues,  as  in  prolonged  and  violent  exertion  or  during  the  progress  of  fevers. 
Carbolic  acid  and  bile  turn  the  urine  brown  or  greenish-black  and  blood  (haema- 
turia)  gives  it  its  characteristic  tinge.  The  normal  odor  of  urine  is  peculiar  to 
itself.  An  artificial  aroma  is  easily  substituted  by  the  ingestion  of  certain  foods 
and  drinks,  as  gaultheria,  turpentine,  asparagus,  etc. 

Reaction. — Health}',  fresh  urine  is  acid  in  reaction,  changing  litmus  from 
blue  to  the  faintest  red  or  rose  color.  Acid  urine  will  at  times  become  alkaline 
within  a  few  minutes  after  its  discharge.  The  ingestion  of  alkaline  substances 
in  vegetable  foods  gives  a  neutral  or  alkaline  character  to  the  urine  passed  within, 
a  short  time  after  eating.  The  same  is  true  of  the  alkaline  salts,  potash,  soda,  etc. 
Urine,  alkaline  in  reaction  as  it  leaves  the  urethra — the  alkalinity  not  due  to  food 
or  medication — is  an  indication  of  disease  of  the  bladder. 

Urea.- — Urea  is  the  result  of  destructive  tissue  metamorphosis.  It  is  increased 
by  the  ingestion  of  nitrogenized  food  and  by  excessive  muscular  exercise,  and  also 
before  the  chills  of  intermittent  fever,  in  diabetes,  chronic  gout,  and  in  the  early 
stages  of  acute  infection.  It  is  also  diminished  after  free  perspiration,  and  as  a 
ride  during  the  later  months  of  pregnancy.  The  quantity  is  diminished  in  prac- 
tically all  the  diseases  of  the  kidneys,  functional  as  well  as  organic. 

The  average  daily  quantity  excreted  by  the  urine  is  about  four  hundred  and 
fift}'  grains,  which,  with  the  estimate  of  the  daily  urine  at  fifty-six  ounces,  is 
about  gr.  j  of  urea  to  5j  of  the  urine. 

Any  marked  diminution  of  this  proportion  indicates  failure  in  the  elimination 
of  the  products  of  waste  in  the  tissues  and  the  danger  of  wcemia.  The  simplest 
quantitative  test,  and  one  sufficiently  exact  for  practical  purposes,  is  the  follow- 
ing :  To  make  it,  it  is  required  to  have  a  Doremus  ureaometer,  which  resembles 
a  medium-sized  test  tulje,  the  open  end  of  which  is  dilated  and  also  bent  at  an 
acute  angle  with  the  rest  of  the  tube,  about  an  inch  and  a  half  from  the  ex- 
panded end.  The  tube  is  filled  with  a  twenty-per-cent  solution  of  caustic  soda  and 
then  one  cubic  centimetre  of  bromine  is  introduced  through  a  pipette.  A  thorough 
admixture  is  secured  by  agitation.  One  cubic  centimetre  of  urine  is  now  carried 
through  a  pipette,  to  the  bottom  of  the  dilated  end  of  the  ureaometer,  well  be3rond 
the  angle,  and  slowly  liberated,  so  that  the  gas  which  is  generated  will  rise  in 
the  long  and  closed  end  of  the  cylinder.  The  percentage  of  urea  (which  is 
represented  by  the  volume  of  nitrogen  evolved)  is  read  oil  from  the  graduated 
scale  fixed  on  the  tube. 

Albuminuria  is  of  two  varieties,  the  tiaie  due  to  renal  derangement  and  the 
false  due  to  blood,  pus,  or,  lymph  in  the  urine.  The  microscope  will  reveal  the 
presence  of  these  bodies  and  aids  in  differentiation.  True  albuminuria  is  usually 
due  to  a  kidney  lesion,  probably  arising  from  an  increased  permeability  of  renal 
epithelium.  It  is  found  in  the  urine  in  venous  congestion,  the  anaemias,  occluded 
ureter,  vesical  retention  during  epileptic  attacks,  in  leukaemia,  chlorsa,  severe 
diarrhoea  and  lead  colic.  It  is  most  abundant  in  acute  nephritis,  when  it  may 
reach  as  high  as  one  per  cent  or  more.  In  chronic  nephritis  it  is  less  abundant 
and  is  j)ractically  always  joresent  in  severe  infectious  diseases. 

Albuminuria  is  usually  accompanied  by  casts,  and  ordinarily  the  more  albumin 
the  more  abundant  the  casts.  They  are  characteristic  plugs  formed  in  the  renal 
tubules,  and  are  easily  recognized  hj  the  microscope.  They  are  nearly  all  made 
up  of  a  translucent  hyaline  substance  (hyaline  casts).  When  they  are  studded  with 
epithelial  cells  they  are  known  as  epithelial  casts  and  strongly  suggest  renal  desqua- 


530  THE   BLADDER 

mation.  When  they  contain  granules  (granular  casts)  they  indicate  disintegration 
of  the  renal  epithelium.  When  fat  globules  are  observed  in  these  bodies,  they  are 
known  as  fatty  casts;  when  blood  cells  predominate.  Mood  casts;  and  when  white 
cells  are  present, -ptis  casts. 

Not  so  frequently  seen  is  another,  the  waxy  cast,  which  appears  during  the 
later  stages  of  nephritis.  It  is  commonly  stained  a  light  yellow  from  the  pig- 
ments of  the  iirine.  Any  or  all  varieties  of  casts  may  be  present  in  the  various 
forms  of  nephritis.  They  do  not  usually  accompany  the  albuminuria  of  febrile 
or  congestive  disturbances. 

Albumin  is  always  present  in  urine  which  contains  pus,  independent  of  any 
affection  of  the  kidneys. 

It  may  be  recognized  by  the  tests  with  heat  and  nitric  acid.  To  employ  the 
heat  test,  fill  a  tube  half  full  of  urine,  to  which,  if  alkaline  or  faintly  acid  in 
reaction,  one  or  two  drops  of  acetic  acid  should  be  added.  Hold  the  tube  so  that 
the  flame  of  the  spirit  lamp  will  heat  the  upper  inch  of  urine.  If,  just  before 
the  boiling  point  is  reached,  a  cloudy  white  film  pervades  the  heated  mass,  the 
presence  of  albumin  is  demonstrated. 

The  nitric-acid  test  is  not  so  reliable  as  the  preceding.  When  albumin  is 
thought  to  be  demonstrated  by  its  use,  the  heat  test  should  be  applied  to  con- 
firm it.  Into  a  small  test  tube  drop  from  TTLx-xx  of  pure  nitric  acid.  Hold  the 
tube  slanting  and  allow  the  urine  from  a  glass  piipette  to  run  gently  down  the 
side  until  it  floats  upon  the  acid.  Albumin  is  indicated  by  a  white  or  cloudy 
ring  formed  in  the  layer  of  urine  immediately  in  contact  with  the  acid. 

Sugar. — The  urine  of  diabetes  mellitus  has  a  high  specific  gi-avity,  is  passed  in 
great  quantity,  and  has  a  characteristic  sweet  odor.  This  form  of  sugar  may 
be  recognized  by  Trommer's  test,  in  which  an  oxide  of  copper  is  produced  by  boil- 
ing diabetic  urine  (grape  sugar)  with  a  solution  of  potash  and  copper.  Fill  a 
test  tube  for  one  inch  with  the  suspected  urine,  and  add  one  or  two  drops  of  a 
solution  of  sulphate  of  copper — ^just  enough  to  give  the  whole  a  pale-blue  tint. 
Add  the  potash  solution  in  quantity  equal  to  one  half  the  urine.  When  sugar  is 
present,  a  pale-blue  hydrated  oxide  of  copper  will  be  thrown  down  and  immedi- 
ately redissolved.  If  the  mixture  is  now  slowly  heated  to  near  the  boiling  point, 
a  reddish-brown  suboxide  of  copper  will  be  precipitated.  Objections  to  the  copper 
tests  are  lack  of  stability  of  the  solutions  and  the  fact  that  excessive  uric  acid  and 
creatinin  occasionally  prodiice  the  sugar  reaction.  The  most  satisfactory  sugar 
test  is  ISTylander's.  The  formida  for  the  solution  is:  Eochelle  salts,  4  parts; 
caustic  soda,  10  parts;  water  100  parts.  Heat  to  the  boiling  point,  add  bismuth 
subnitrate  to  saturation  (about  two  parts),  and  filter.  To  eight  parts  of  urine 
in  a  test  tube  add  one  part  of  the  solution,  and  heat  imtil  a  white  cloudy  precipi- 
tate is  produced,  which,  if  sugar  be  present,  turns  an  intense  black  on  standing  a 
few  minutes. 

When  a  quantitative  analysis  is  desired,  tlie  fermentation  test  will  be  found 
simple  and  sufficiently  accurate  for  practical  use.  Fill  a  wide-mouthed  bottle  with 
the  urine,  and  register  the  specific  gravity  at  the  time.  Place  a  small  piece  of 
yeast  in  the  urine,  and  set  it  aside  in  a  warm  place  for  from  twelve  to  eighteen 
"hours,  until  fermentation  has  occurred,  and  again  take  the  specific  gravity.  The 
difference  in  degrees  of  the  urinometer,  as  registered  before  and  after  fermenta- 
tion, ■mil  represent  the  number  of  grains  of  sugar  in  the  ounce  of  urine. 

Indican  is  a  product  derived  from  putrefactive  changes  in  the  alimentary  canal, 
and  usually  follows  overeating  and  indigestion.  Its  presence  suggests  a  low  re- 
sistance which  should^  if  possible,  be  corrected  before  an  operation  is  undertaken. 
It  is  also  present  as  a  result  of  obstruction  in  the  small  intestines,  but  not  in 
obstruction  of  the  colon. 

Calcium  oxalate  is  a  normal  constituent  of  the  urine,  and  varies  in  quantity 
from  ten  to  twenty  milligrams  per  day.  The  crystals,  when  precipitated,  are 
commonly  small,  octahedral,  colorless  bodies,  occasionally  oval  and  dumb-bell 
shaped.  About  sixty  per  cent  of  renal  and  vesical  calculi  are  made  up  of  calcium 
oxalate  in  whole  or  in  part.  Persons  affected  should  refrain  from  tomatoes  and 
rhubarb,  and  the  general  diet  should  be  so  restricted  as  to  maintain  a  proper  diges- 


THE   BLADDER  531 

tion.  In  its  elimination,  in  addition  to  regularitj'  of  diet,  the  imbibition  of  large 
quantities  of  "water  one  or  two  hours  after  meals  is  indicated. 

Acetone  appears  in  the  urine  under  various  conditions,  but  it  is  onl}^  significant 
when  found  in  diabetes,  and  under  such  conditions  is  of  grave  import. 

A  simple  method  of  testing  for  acetone  is  to  add  to  half  a  test  tube  of  urine  a 
few  drops  of  a  strong  solution  of  sodium  hydrate,  and  to  this  a  few  drops  of  a  five- 
per-cent  solution  of  nitroprusside  of  sodium,  and  if  upon  the  addition  of  a  few 
drops  of  glacial  acetic  acid  to  the  mixture  the  color  changes  to  a  piirple,  acetone 
is  present.    In  the  absence  of  acetone  the  acetic  acid  causes  no  deepening  of  color. 

Bile  in  the  urine  always  imparts  to  it  a  high  color  which  may  vary  from  a 
dark  yellow  or  light  brown  to  a  deep  brown,  or  it  may  be  greenish,  especially  if 
it  has  been  allowed  to  stand.  The  foam  of  such  urine  is  colored  a  light  yellow, 
and  the  urinary  sediments  are  also  stained  a  deep  yellow  color.  It  may  be  further 
observed  that  whenever  it  comes  in  contact  with  linen  it  leaves  a  yellow  stain. 

A  simple  test  for  the  presence  of  bile  is  to  moisten  a  piece  of  filter  paper  with 
the  urine  and  place  on  it  a  drop  of  nitrous  acid.  If  bile  be  present  a  green  color 
will  appear  at  the  margin  of  the  drop.  Other  colors  will  appear  even  in  the 
absence  of  bile,  biit  the  green  only  is  significant  of  bile. 

Albumin  and  casts  are  usually  present  in  urines  containing  bile. 

It  is  ordinarily  noticeable  in  the  urine  before  the  jaundice  is  observed  in  the 
skia  and  mucous  membranes. 

It  occurs  in  all  instances  of  obstruction  to  the  flow  of  bile  from  the  gall 
bladder,  hence  it  will  l>e  found  in  many  of  the  liver  disturbances,  such  as  catarrhal 
Jaundice,  cirrhosis  of  the  liver,  gallstones,  and  cancer  of  the  liver. 

Pus-  and  Blood-coi-piisdes — Epithelia. — Pus  cells  in  the  urine  may  come  from 
an  inflammation  in  any  portion  of  the  iirinary  tract,  from  the  kidney  to  the  meatus, 
or  from  the  communication  of  a  sinus  or  abscess  with  the  urinary  apparatus. 
Urine  containing  pus  may  be  acid,  alkaline,  or  neutral  in  reaction.  In  acid  urine 
the  corpuscles  are  prominent  and  easily  recognized;  when  the  reaction  is  alkaline, 
they  are  usually  destroyed,  and  appear  as  ropy  or  gelatinous  strings,  more  resem- 
bling mucus  than  pus.  if  the  urine  is  examined  immediately  after  being  passed, 
a  few  corpuscles  may  be  recognized.  When  allowed  to  stand  for  some  minutes 
the  pus  cells  collect  in  the  bottom  of  the  vessel.  Examiaed  with  the  microscope, 
they  are  seen  to  be  spherical  and  faintly  granular.  On  account  of  the  absorption 
of  water  they  are  swollen  and  less  distinct  than  pus  cells  from  a  recent  aljscess. 
The  addition  of  acetic  acid  renders  the  nuclei  more  distinct.  The  source  of  pus 
found  in  the  urine  may  frecjuently  be  determined  from  the  symptoms  present,  to- 
gether with  the  microscopical  appearances  of  the  urine.  If  with  the  pus-corpuscles 
flat,  large  epithelia  are  abundant,  the  inflammatory  process  is  in  all  probability 
situated  in  the  bladder,  where  these  epithelia  belong.  In  females  a  larger,  flat 
epithelium  from  the  vagina  often  finds  its  way  into  the  urine.  The  cells  from 
the  vagina  are  more  often  disposed  in  drifts  or  groups  than  the  bladder  epithelia. 
Large  spherical  or  polygonal  cells  may  come  from  the  kidney  tubules  or  the  male 
urethra.  They  are  about  twice  the  size  of  a  pus-corpuscle.  Whether  they  are 
derived  from  the  kidney  or  the  urethra  may  in  great  part  be  determined  by  the 
presence  or  absence  of  urethritis.  Conical  or  ham-shaped  cells  may  come  from 
the  pelvis  of  the  kidney,  prostate,  and  glandular  apparatus  of  the  urethra.  They 
are  usually  not  so  abundant  as  the  other  varieties. 

Hamaturia. — Blood  in  the  itrine  may  come  from  traumatic  or  idiopathic 
hfemorrhage  into  the  Malpighian  tufts  or  kidney  tubules;  from  the  pelvis  or 
ureters  as  a  result  of  calculi  or  ulceration;  from  the  bladder  as  a  result  of  in- 
strumentation, calculi,  wounds,  foreign  bodies,  neoplasms,  ulceration,  parasites, 
or  the  hemorrhagic  diathesis;  from  the  prostate  or  accessory  organs  and  from  the 
urethra. 

The  administration  of  certain  remedies  may  account  for  the  appearance  of 
blood  in  the  urine.  Haematuria  occurs  at  times  as  a  sjTnptom  of  malarial  fever, 
and,  in  women,  as  a  form  of  vicarious  menstruation. 

Blood  in  the  urine  may  be  recognized  bv  its  characteristic  coagula,  by  the 
red  or  reddish-brown  color  'it  imparts  to  this  fluid,  the  presence  of  the  corpuscles 


532  THE   BLADDER 

under  the  microscoije,  or  the  fibrinous  casts  of  tlie  tubules  of  tlie  kidney  or  ure- 
ters. In  rare  instances  the  blood  disks  are  entirely  destroyed,  and  the  coloring 
matter  set  free.     This  condition  is  apt  to  occur  in  ammoniacal  urine. 

When  urine  containing  blood  is  boiled,  a  white  or  cloudy  coagulum  is  formed, 
its  density  depending  upon  the  quantity  of  blood  present. 

If  bloody  urine  is  allowed  to  stand  without  being  agitated,  the  corpuscles  settle 
to  the  bottom  of  the  vessel,  and  may  be  recognized  by  their  red  or  amber  color. 
Under  the  microscope  they  may  assume  different  shapes.  In  acid  urine  the  disks 
retain  their  biconcave  conformation  for  a  long  time.  When  the  hcemorrhage  is 
slight,  they  float  isolated;  if  profuse,  they  may  be  caught  in  coagula  or  collect 
in  rouleaux.  If  the  reaction  is  feebly  acid,  or  where  the  corpuscles  are  submitted 
for  a  considerable  time  to  the  action  of  the  urine,  they  lose  their  biconcave  shape, 
and  become  distended,  swollen,  and  spherical.  They  may  be  recognized  from 
pus-eor23uscles  by  their  smaller  size,  transparenc}'',  and  in  not  containing 
granular  bodies.  At  times  they  retain  their  flat  shape  and  appear  with  ser- 
rated edges. 

Blood  casts  usually  come  from  the  kidney  tubules,  and  are  composed  of  fibrin 
in  which  the  red  disks  are  entangled  in  varying  proportion.  In  some,  large  clus- 
ters or  groups  of  blood-corpuscles  are  seen,  with  an  occasional  epithelial  cell  from 
the  kidney  or  urinary  passages.  When  the  disks  have  been  completely  destroj^ed, 
as  in  the  decomposition  of  the  coloring  matter  in  ammoniacal  urine,  and  the 
organic  elements  of  the  blood  are  not  recognizable  with  the  microscope,  the 
spectroscope  may  be  relied  upon  to  demonstrate  the  presence  of  the  coloring 
matter. 

In  determining  the  source  of  blood  in  hsematuria  the  following  points  should 
be  considered :  When  the  bleeding  is  urethral,  the  first  discharge  of  urine  is  most 
deeply  colored.  A  clot  of  blood  preceding  or  accompanying  the  discharge  of  urine 
indicates  urethral  hEemorrhage.  In  males,  if  spermatozoa  are  entangled  in  the 
coagula,  the  suspicion  of  htemorrhage  from  the  vasa  deferentm,  vesiculce  seminales, 
or  prostatic  apparatus  is  entitled  to  consideration,  although  the  fact  must  not  be 
overlooked  that  these  elements  may  mingle  in  the  urethra  with  blood  from  any 
part  of  the  urinary  passages. 

When  the  bleeding  is  from  the  pelvis  of  the  kidney  pain  and  other  symptoms 
of  stone  or  pyelitis  will  often  precede  the  hsematuria.  Not  infrequently,  however, 
the  haemorrhage  is,  next  to  the  presence  of  pus  in  the  urine,  the  first  indication 
of  pyelitis. 

In  haemorrhage  from  the  bladder  there  are  often  symptoms  of  cystitis  which 
will  point  directly  to  this  organ  as  the  source  of  the  bleeding.  In  differentiating 
the  source  of  blood  from  the  kidneys,  ureters,  and  the  bladder,  the  method  of 
Thompson  and  Van  Buren  may  be  resorted  to  with  success.  Introduce  a  soft 
catheter  just  within  the  neck  of  the  bladder,  draw  off  the  contained  urine,  and 
wash  out  the  organ  with  clean  water.  If,  during  the  irrigation,  the  water  which 
flows  away  contains  blood,  the  haemorrhage  is  from  the  bladder  walls.  If  it  flows 
away  clear,  then  empty  the  bladder,  place  the  flnger  over  the  end  of  the  catheter, 
allow  it  to  remain  introduced,  and  wait  until  a  small  quantity  of  urine  has  accu- 
mulated. This  is  drawn  off,  and,  if  it  is  blood}',  and  if  the  clear  water  now  thrown 
in  comes  out  unstained,  the  inference  is  fair  that  the  bleeding  is  from  the  ureters 
or  beyond.  The  cystoscope  should  be  employed  in  cases  in  which  doubt  may  exist 
after  the  foregoing  methods  have  been  tried. 

Haemorrhage  from  the  urethra  is  rare  except  from  violence,  the  lodgment  of 
calculi,  or  from  ulceration. 

Heematuria  due  to  parasitic  lodgment  in  the  walls  of  the  bladder  is  exceed- 
ingly rare  in  this  country.  In  1883  a  young  man  of  white  parents — a  native  of 
Natal,  Africa — came  under  my  care  on  account  of  chronic  hfematuria.  He  was 
at  this  time  twenty-six  years  of  age,  and  had  had  bloody  urine  at  intervals  for 
thirteen  years.  His  health  was  not  seriously  impaired.  The  urine  was  faintly 
acid;  speeiflc  gravity  1.020,  with  only  a  trace  of  albumin,  which  was  readily  ac- 
counted for  by  the  slight  amount  of  blood.  About  the  middle  and  toward  the  last 
stage  of  the  act  of  micturition  a  few  strings  of  clotted  blood  were  discharged. 


THE   BLADDER  533 

Placing  these  under  the  microscope.  I  discovered  a  number  of  bodies  (Fig.  538) 
shaped  much  like  a  watermelon  seed,  except  that  the  small  end  was  more  pointed. 
These  were  evidently  the  eggs  of  the  parasite  known  as  Bilharzia  hcematohia,  the 
hematuria  resulting  from  the  rupture  of  capillaries  caused  by  the  presence  of 
nests  of  these  ova  in  the  mucous  membrane  of  the  bladder.  This  disease  is  fre- 
quent in  Africa  and  Asia,  but  almost  unknown  in  Xorth 
America.  The  body  of  the  male  parasite  is  about  four 
lines  in  length,  threadlike,  and  flattened  anteriorly  (Ait- 
ken)  ;  the  female  a  little  shorter  and  more  delicate.  They 
inhabit  by  preference  the  portal  vein  and  the  walls  of  the 
bladder.  In  treating  my  patient  I  saturated  him  with  large 
doses  of  santonin  for  a  week,  and  injected  the  bladder  daily 

with  alcohol,  beginning  with  a  1-20  solution,  and  inereas-  ^qo  _,  o  -       B-a 

ing  it  to  the  extreme  degree  of  tolerance  by  the  bladder.  imrzia  hanmMa.    2" 

The  patient  improved  in  every  respect,  but  the  ligsmaturia  Crenated  blood  disks, 

was  not  entirely  arrested  when  he  returned  to  Africa,  in  cell.'"*(Fro'm^'the'  au- 

JSTovember,  1883,  since  wloich  time  I  have  not  heard  from  thor's  case.) 

him. 

The  parent  distoma  is  killed  by  high  febrile  movement,  and  with  its  death 
the  hsematuria  ceases. 

Chemically  blood  may  be  detected  by  adding  to  some  urine  in  a  test  tube 
about  two  cubic  centimetres  of  tincture  of  guiac  and  the  same  amount  of  old 
turpentine.  The  mixture  is  then  agitated,  and  if  blood  or  pus  be  present  the 
mixture  will  become  blue  in  color. 

The  treatment  of  hematuria  must  be  directed  to  the  disease  of  which  it  is  a 
symptom.  The  patient  should  be  required  to  remain  in  the  recumbent  posture. 
Large  doses  of  citrate  of  potash  will  prove  beneficial  in  rendering  the  urine  less 
irritating.  Opium  is  advisable,  not  only  on  account  of  the  relief  from  pain  it 
affords,  but  because  it  secures  complete  quiet,  which  is  essential,  and  prevents  the 
too  frequent  evacuation  of  the  bladder. 

When  the  hsmorrhage  is  from  this  organ,  and  does  not  yield  to  the  measures 
above  given,  the  injection  of  cold  or  hot  water,  or  of  astringent  solutions,  may  be 
employed.     If  villous  growths  are  present,  they  should  be  removed  by  cystotomy. 

Tumors  of  the  kidneys,  omentum,  retroperitoneal  glands,  stomach,  pancreas, 
and  even  the  uterus  and  ovaries  may  interfere  with  the  outflow  of  bile,  and 
thereby  cause  its  appearance  in  the  urine. 

Among  the  pathogenic  bacteria  found  in  the  urine  are  streptococcus,  staphylo- 
coccus, gonococcus,  colon  bacillus,  typhoid  baciUus,  and  tubercle  bacillus.  Of 
these,  the  gonococcus,  streptococcus,  and  tubercle  bacillus  are  easily  discovered  if 
the  urine  be  thoroughly  centrifuged  and  the  sediment  be  examined  in  smear  prepa- 
rations as  advised  for  these  organisms.  The  tv^^hoid  bacillus  is  commonly  present 
in  the  urine  during  the  course  of  an  attack  of  typhoid  fever,  and  it  occasionally 
persists  for  some  time  after  recovery. 

Parasites  in  the  urine  are  not  numerous.  Perhaps  the  most  common  is  the 
tricomonas,  which  is  probably  the  same  as  the  tricomonas  intestinalis  of  the 
faeces.  It  has  no  diagnostic  importance.  In  eehinococcus  cysts  of  the  kidney  the 
booklets  sometimes  appear  in  the  urine  together  with  fragments  of  the  cysts. 
Filaria  sanguinis  embryos  are  sometimes  found  in  the  urine  of  those  afHicted  with 
this  parasite.  Finally,  as  above  given,  the  eggs  of  Bilharzia  hsematobia  are  found 
in  the  urine  in  countries  where  that  parasite  abounds. 

The  deodorization  of  foul  urine  is  effected  by  the  administration  of  oil  of  gaul- 
theria  5ij,  salol  oj,  in  doses  of  gtt.  xx  three  times  daily. 

Stoxe  in  the  Bladder 

Urinary  calculi  may  form  in  any  portion  of  the  kidney,  in  the  pelvis  or  ureters, 
in  the  bladder  or  urethra.  They  are  concretions  of  the  various  inorganic  sub- 
stances which  are  common  to  the  urine.  Organic  particles,  such  as  epithelia, 
mucus,   and  various   iniiammatory  products,   often   enter   into   the   formation   of 


534  THE   BLADDER 

calculi.  When  an  aggregation  of  the  urinary  salts  occurs  within  the  kidney  tu- 
bules, the  probabilities  are  that  the  stone  so  formed  will  remain  imprisoned  in 
this  organ  (renal  calculus)  until  removed  by  ulceration  or  operation.  Forming 
in  the  larger  straight  tubes  of  the  pyramids,  a  urinary  concretion  may,  while  yet 
minute,  escape  into  the  calix  and  pelvis,  and  pass  down  the  ureter  into  the  blad- 
der, or  remain  lodged  in  the  pelvis  or  excretory  duct. 

It  is,  moreover,  probable  that  the  majority  of  calculi  found  in  the  bladder,  or 
passed  by  the  urethra,  originate  as  concretions  in  the  straight  tiibes,  calices,  or 
pelves  of  the  kidneys,  whence  they  drift  outward  to  the  bladder,  and  there  by  con- 
tinued accretion  become  large  enough  to  attract  attention,  even  if  the  transit 
along  the  ureter  was  unnoticed.  Undoubtedly  a  fair  proportion  of  vesical  calculi 
are  formed  in  this  organ  proper,  and  the  greater  number  of  these  may  be  grouped 
in  the  class  of  calculi  which  form  around  nuclei  composed  of  foreign  substances, 
or  animal  matter,  such  as  epithelia,  inflammatory  products,  etc.  Conversely,  it 
is  admitted  that  animal  matter  may  form  the  nucleus  of  a  kidney  or  pelvic  con- 
cretion, while  a  bladder  calculus  may  also  be  formed  by  accretion  of  the  purely 
inorganic  elements  of  the  urine. 

A  calculus  is  rarely  of  u.niform  composition,  more  frequently  combining  two 
or  more  inorganic  as  well  as  organic  elements  in  its  formation.  In  the  nomen- 
clature it  is  the  practice  to  give  to  the  stone  the  name  of  the  preponderating 
element. 

That  most  commonly  observed  is  composed  principally  of  uric  acid  and  the 
urates.  These  stones  are  of  fair  consistency,  yellowish  or  light  brown  in  color, 
not  very  smooth  when  single,  yet  not  so  rough  as  oxalate-of-lime  concretions.  They 
may  attain  a  diameter  of  two  or  three  inches.  As  a  rule,  they  form  in  urine  which 
is  distinctly  acid  in  reaction. 

The  mulberry  or  oxalate-of-lime  calculus  is  next  in  order  of  frequency,  and 
relatively  more  so  in  children  than  in  adults.  It  may  exist  in  all  sizes,  and  varies 
greatly  in  color.  The  smaller  concretions  are  light  in  color  and  fairly  smooth; 
the  larger  are  exceedingly  rough,  with  jagged  edges,  and  are  dark  brown  in  color, 
in  rare  instances  white.  Oxalate-of-lime  calculi  usually  commence  in  the  kidney, 
and  pass  as  small  particles  to  the  bladder.  The  most  severe  forms  of  "  renal  colic  ■" 
are  due  to  the  slow  and  painful  passage  of  these  rougher  concretions  along  the 
iireters. 

Phosphatic  calculi  come  next  in  order  of  frequency,  and  are  divisible  into  three 
classes:  the  ammonio-magnesian  and  'pliospliate-of-lime  (fusible),  neutral  phos- 
phate of  lime,  and  ammonio-magnesian  calculi. 

Fusible  calculi  are  more  often  met  with  than  the  other  two  forms  of  phosphatic 
concretions.  The}'  are  gray  or  white  in  color,  readily  friable,  and  light.  The  hard- 
ness is  proportionate  to  the  lime  phosphate  present.  They  attain  large  size,  and 
conform  themselves  to  the  shape  of  the  bladder. 

The  neutral  phosphate-of-time  calculus  is  rare.  It  may  form  in  the  kidney, 
though  it  originates  chiefly  in  the  bladder.  All  the  phosphatic  calculi  are  chiefly 
vesical  in  origin,  being  found  with  ammoniacal  urine,  which  is  present  with 
chronic  vesical  catarrh.  The  ammonio-^nagnesian  phosphatic  concretion  is  equally 
rare,  and  differs  very  slightly  in  its  chemical  and  physical  characters  from  that 
just  described. 

Other  and  still  rarer  forms  of  urinary  concretions  are  the  following: 

Gystin. — This  variety  is  usually  smooth,  occasionally  corrugated,  yellow  in 
color  when  fresh,  inclining  to  a  greenish  hue  when  long  removed.  They  break 
readily,  do  not  show  a  marked  concentric  arrangement,  and  are  somewhat  greasy 
to  the  feel. 

Xanthic  or  uric-oxide  calculi  have  only  been  reported  in  two  or  three  instances. 
They  are  of  concentric  formation,  smooth  and  greasy  to  the  feel,  and  vary  in  color 
from  gray  to  brown. 

Garbonate-of-lime  calculi  are  usually  multiple,  and  are  light  gray  in  color  and 
chalky  in  consistence. 

Organic  calculi,  consisting  of  epithelia,  blood,  etc.,  are  not  infrequent  as  nu- 
clei for  other  varieties,  but  exceedingly  rare  as  independent  forms. 


THE   BLADDER  535 

Stone  in  the  bladder  is  a  misfortune  that  may  befall  every  age  and  condition 
of  human  life,  from  the  foetus  in  utero  to  the  old  and  decrepit.  The  period  of 
greatest  exemption  is  from  twenty  to  fifty  years  of  age.  It  is  comparatively  fre- 
quent in  children,  and  here  must  be  chiefly  of  renal  origin  and  due  to  the  excess 
of  inorganic  elements  in  the  urine,  since  obstruction  and  inflammatory  diseases 
of  the  urinary  tract  rarely  exist  at  this  age.  After  fifty,  when  prostatic,  cystic, 
and  urethral  obstruction  are  more  frequently  met  with,  the  formation  of  calculi, 
vesical  in  origin,  is  more  common.  As  to  sex,  stone  is  more  frequent  in  males. 
It  was  formerly  argued  that  there  was  no  difference  in  the  frequency  of  stone  in 
the  sexes,  but  that  the  short  and  dilatable  iirethra  of  the  female  allowed  a  ready 
escape  to  the  concretion  before  it  became  sufficiently  large  to  produce  any  organic 
disturbance.  When,  regardless  of  the  statistical  evidence  which  shows  that  the 
number  of  deaths  in  males  from  urinary  calculus  is  ten  times  greater  than  in 
females,  we  consider  that  one  of  the  most  frequent  causes  of  stone  is  the  gouty 
diathesis,  and  that  gout  is  more  frequent  in  men;  and,  again,  that  prostatic  and 
urethral  obstruction  is  peculiar  to  this  sex — it  must  be  conceded  that  the  conditions 
for  the  formation  of  calculi  are  more  frequently  jjresent  in  males. 

In  the  cetiology  of  stone  in  the  bladder  two  great  factors  are  recognized :  The 
one  includes  all  conditions  of  the  economy  which  favor  precipitation  of  the  inor- 
ganic elements  of  the  urine;  the  second  all  obstructive  and  inflammatory  lesions 
which  produce  decomposition  of  the  urine  in  the  bladder,  the  detachment  of  epi- 
thelia,  and  the  accumulation  of  other  organic  elements  which  serve  as  nuclei 
around  which  the  salts  of  the  urine  are  congregated. 

In  the  first  category  are  hereditary  tendencies,  such  as  gout  and  rheumatism. 
Certain  conditions  of  malnutrition  undoubtedly  lead  to  a  precipitation  of  the 
urinar}^  salts,  for  children  poorly  fed  and  cared  for  are  much  more  apt  to  suffer 
from  calculus  than  those  who  are  well  fed  and  comfortably  clothed  and  sheltered. 

In  the  group  of  local  causes  may  be  classed  all  cystic  diseases  in  which  the 
products  of  inflammation  collect  in  the  bladder  and  form  nuclei,  around  which 
concretions  occur;  prostatic  enlargement  inducing  retention,  cystitis,  and  decom- 
position of  urine;  stricture,  and  all  obstructive  and  inflammatory  lesions  of  the 
urethra  which  may  involve  or  affect  the  integrity  of  the  bladder;  the  presence 
of  any  foreign  matter  in  the  bladder,  or  paralysis  of  the  bladder  from  any  cause. 

Tlie  Symptoms  and  Diagnosis.- — It  may  be  stated  at  once  that,  however  much 
lias  been  and  may  be  said  of  the  value  of  the  various  symptoms  of  stone,  the  diag- 
nosis rests  upon  one  simple  expedient,  the  introduction  of  a  metallic  instrument 
into  the  bladder,  and  in  contact  with  the  stone.  For  this  purpose  the  ordinary 
steel  sound  is  usually  sufficient.  The  bladder  should  be  allowed  to  contain  about 
lialf  a  pint  of  fluid,  and  when  the  instrument  is  introduced  it  should  be  manipu- 
lated so  that  the  convexity  of  the  curve  will  glide  over  the  floor  of  the  bladder 
back  and  forth  from  the  neck  to  the  posterior  wall  of  the  organ,  at  the  same  time 
depressing  the  bladder  toward  the  rectum.  By  this  manoeuvre  the  stone  will  be 
induced  to  gravitate  to  the  deeper  portions  in  contact  with  the  instrument,  or  so 
close  to  it  that  a  sharp,  quick  turn  to  right  or  left  will  bring  the  calculus  and 
metal  into  appreciable  contact.  In  certain  cases  of  prostatic  hypertrophy  the  cal- 
culus may  remain  concealed  immediately  behind  the  enlarged  organ,  and  in  such 
a  position  that  the  sound  cannot  be  brought  in  contact  with  it.  Under  such  con- 
ditions Thompson's  searcher   (Fig.  539)  will  be  found  useful.     The  objection  to 


Fig.  539. — Thompson's  searcher. 

this  instrument  is  the  difficult}'  of  its  introduction  from  the  abrupt  nature  of  the 
curve  near  the  tip.  When  once  introduced  its  value  is  readily  appreciated.  Turn- 
ing its  point  downward  and  moving  as  if  to  withdraw  it,  there  is  no  portion  of 
the  floor  that  it  will  not  thoroughly  search. 


536  THE   BLADDER 

When  a  stone  cannot  be  appreciated  with  a  full  or  half-filled  bladder  it  may 
be  felt  if  this  organ  is  completely  emptied.  Not  only  is  the  calculus  driven  toward 
the  neck  of  the  bladder  when  it  is  emptied  of  urine,  but  the  hardness  and  weight 
are  more  readily  appreciated,  since  it  is  held  in  the  grasp  of  the  organ,  and  cannot 
slip  away  when  the  sound  touches  it.  In  some  forms  of  vesical  calculus  the  stone 
becomes  partially  or  completely  encysted  in  some  portion  of  the  bladder  wall.  The 
calculus  may  drop  into  an  abnormal  pouch  in  the  bladder ;  it  may  sink  by  a  process 
of  iilceratioii  into  the  walls,  and  be  partially  or  completely  surrounded  by  a  newly 
formed  inflammatory  tissue,  or  it  may  have  been  lodged  in  the  ureter  near  its 
termination. 

Again,  a  stone  may  be  caught  in  the  upper  portion  of  the  bladder  without  being 
sacculated.  In  sounding  for  stone  in  adults  narcosis  is  rarely  reciuired,  especially 
where  there  are  no  symptoms  of  severe  cystitis  and  tenesmus.  In  children  an 
anEesthetie  should  always  be  employed.  When  the  calculus  cannot  be  felt  after 
careful  search  it  is  at  times  a  successful  expedient  to  introduce  the  finger  into  the 
rectum  and  make  upward  pressure  upon  the  base  of  the  bladder,  and  firm  pressure 
downward  upon  the  abdomen  just  above  the  symphysis  pubis. 

Vesical  calculus  may  be  suspected  in  a  patient  who  has  had  renal  colic,  or 
has  passed  by  the  urethra  particles  of  gravel,  and  afterward  develops  a  cystitis. 
Not  infrequently,  however,  a  concretion  goes  from  the  kidney  into  the  bladder 
without  attracting  the  attention  of  the  patient.  If  it  lodges  here  and  increases 
slowly  in  size,  it  may  remain  for  months  or  years  without  giving  any  symptoms 
of  cystitis,  or  marked  annoyance.  Usually,  however,  when  a  stone  is  present,  and 
is  so  light  and  smooth  that  it  does  not  affect  the  mucous  membrane  of  the  blad- 
der, it  attracts  attention  by  mechanical  interference  with  the  escape  of  urine, 
dropping  at  times  into  the  orifice  of  the  urethra,  and  suddenly  shutting  off  the 
flow  during  micturition.^ 

When  a  stone,  by  reason  of  its  size,  weight,  and  roughness,  begins  to  cause  cys- 
titis, frequent  micturition  is  a  prominent  symptom.  A  burning  or  smarting  pain, 
referred  to  the  end  of  the  penis,  is  a  frequent  symptom  in  this,  as  in  idiopathic 
inflammation  of  this  organ.  At  times  the  pain  is  referred  to  the  scrotum,  penis, 
uterus,  and  other  organs,  or  along  the  nerve  tracts  in  the  lower  extremities.  In 
any  jolting  movement,  as  in  riding  on  horseback  or  in  vehicles  without  springs, 
or  in  walking  about,  the  pain  is  increased.  Tenesmus  is  often  violent  toward  the 
end  of  urination,  when  the  stone  is  grasped  by  the  contracting  bladder.  The 
urine  almost  always  contains  pus,  and  blood  is  frequently  present.  Hsematuria, 
with  calculus,  occurs  chiefly  during  the  waking  hours,  when  the  patient  is  moving 
about.  It  is  more  apt  to  be  met  with  in  oxalate-of-lime  calculi  than  in  the  other 
varieties.  In  the  rare  instances  in  which  stone  exists  with  villous  growths  of 
the  bladder,  haemorrhage  is  often  excessive.  When  a  calculus  is  of  large  size  it 
may  by  pressure  produce  pain  and  symptoms  of  disturbance  in  other  organs,  as 
the  vagina,  uterus,  or  rectimi.  The  size  and  character  of  a  stone  in  the  bladder 
may,  in  a  measure,  be  determined  by  exploration  with  the  sound,  as  well  as  by 
palpation. 

A  large  stone  is  usually  felt  as  soon  as  the  sound  enters  the  neck  of  the  blad- 
der. The  sense  of  resistance  is  greater,  and  a  fair  idea  of  its  proportions  may  be 
made  out  by  passing  the  metallic  sound  along  its  surfaces.  A  small  stone  is 
often  with  difficulty  recognized.  Pressure  above  the  symphysis  pubis,  and  intra- 
vaginal  or  rectal  exploration,  are  not  without  value  in  estimating  the  size  of  a 
calculus.  If  the  click  of  the  sound  is  sharp  and  clear,  and  if  the  surface  is  rough 
and  grating  to  the  sense  of  touch  conveyed  along  the  instrument,  an  oxalate-of- 
lime  stone  may  be  suspected,  and,  if  the  patient  is  a  child,  the  suspicion  is  strength- 
ened. Hsematuria,  and  all  the  symptoms  of  cystitis,  are,  as  a  rule,  increased  with 
this  form  of  calculus.  In  patients  with  the  gouty  or  Theumatic  diathesis,  uric- 
acid  stone  is  the  rule.  The  acidity  of  the  urine  in  a  measure  excludes  phosphatic 
calculus.  In  the  exceptional  instances  in  which  a  portion  of  the  surface  of  the 
bladder  has  become  incrusted  with  the  inorganic  elements  of  the  urine,  this  con- 
dition may  be  determined  by  the  immobility  of  the  concretion  when  the  sound  is 
brought  in  contact  with  it.     The  absence  of  a  spherical  calculus  can  be  determined 


THE   BLADDER 


537 


by  digital  exploration  through  the  rectum  or  yagina,  combined  with  pressure  from 
above  the  symphysis  pubis. 

The  proper  treatment  of  stone  in  the  bladder  may  be  divided  into  the  curative 
and  palliative.  To  the  former  belong  the  operations  of  lithotomy  and  lithotriiy; 
to  the  latter  are  systematic  medication  and  hygiene,  together  with  the  employment 
of  all  local  means  calculated  to  relieve  pain  and  prolong  life.  The  conditions  under 
which  lHhoirity  should  he  preferred  to  suprapubic  lithotomy  are  rare,  and  are 
given  with  the  description  of  the  operation. 

Lithotrity. — If  the  symptoms  are  not  so  distressing  as  to  demand  immediate 
interference,  from  ten  days  to  two  weeks  should  be  devoted  to  the  careful  prepara- 


G.TIEMAlgr. 
Fig.  540. — Fenestrated  jaws  of  Thompson's  Uthotrite. 


tion  of  the  patient.  It  is  not  only  important  to  improve  the  general  condition, 
but  also  to  accustom  the  urethra  to  the  introduction  of  the  sound.  Strict  adher- 
ence to  the  practice  of  antisepsis,  as  given  for  the  bladder  and  urethra,  is  required. 

The  instruments  required  are  the  lithotrite  and  an  apparatus  for  washing  out 
the  detritus. 

Of  the  various  crushing  instruments  which  have  been  introduced,  that  of  Sir 
Henry  Thompson  is  to  be  preferred  (Fig.  543).     It  is  commendable  for  its  light- 


Fig.  541. — Male  blade  of  Thompson's  lithotrite. 


G.TiEMAMN  iCO 

Fig.  542. — Female  blade  of  Thompson's  lithotrite 


ness,  strength,  and  smooth  action.  With  the  heavier  instruments  the  sense  of 
touch  is  not  so  delicate  and  acute.  The  lighter  lithotrite  is  strong  enough  to 
crush  any  calculus  which  may  be  safely  removed  by  this  operation.  Moreover, 
it  is  especially  to  be  commended  for  the  fenestrated  jaw  in  the  female  blade,  which 
allows  the  male  blade  to  pass  entirely  through,  and  thus  avoids  the  danger  of 


li.TIEriJANN.  CO.N.  ir 

Fig.  543. — Thompson's  lithotrite  adjusted. 


choking  and  fouling.  It  consists  of  a  male  blade  (Fig.  541),  or  sliding  rod, 
which  fits  into  a  fixed  or  female  blade  (Fig.  542),  which  is  deeply  hollowed  out 
for  its  reception. 

The  seizing  and  crushing  action  of  the  lithotrite  is  double.  When  the  male 
blade  is  carried  through  the  hollow  handle  into  the  slot  in  the  female  blade,  a 
simple  and  rapid  to-and-fro  movement  can  be  executed  by  pushing  or  pulling  on 
the  male  blade  with  the  right  hand,  while  the  left  steadies  the  female  blade,  to 


538  THE   BLADDER 

which  the  handle  is  attached.  This  movement  can  be  made  very  effective  in  seizing 
the  stone  and  in  crushing  the  smaller  fragments  without  taking  the  extra  time 
in  sliding  the  catch  which  throws  on  the  screw  motion  of  the  instrument. 

Wlien,  however,  a  stone  is  caught  in  its  grasp  b}^  the  sliding  movement  just 
described,  and  is  so  solid  and  resisting  that  a  sufficient  and  safe  crushing  force 
cannot  be  employed,  the  catch  on  the  top  of  the  handle  is  slipped  upward.  The 
sliding  movement  is  now  impossible,  and  the  more  powerful  screw  motion  sub- 
stituted. By  turning  the  wheel  at  the  end  of  the  male  blade  to  the  right,  the 
stone  can  be  felt  to  give  way  under  the  crushing  force. 

In  the  removal  of  vesical  calculi  by  this  operation  two  procedures  are  recog- 
nized, viz.,  complete  and  incomplete  lithotrity. 

In  the  former,  or  Bigelow's  method,  narcosis  is  required;  the  stone  is  entirely 
crushed,  and  the  fragments  washed  out  at  a  single  operation.  In  the  latter,  antes- 
thesia  is  not  employed;  the  calculus  is  only  partially  comminuted,  and  the  frag- 
ments are  left  to  pass  off  with  the  urine. 

Complete  lithotrity  has  almost  entirely  superseded  the  older  operation.  It  is 
preferable  in  all  cases  where  the  condition  of  the  patient  justifies  the  risk  of  shock 
from  a  capital  operation  under  narcosis. 

Operation. — The  patient,  being  narcotized,  is  placed  upon  the  operating  table, 
in  the  dorsal  decubitus,  with  the  pelvis  raised  about  half  a  foot  by  pillows  placed 
under  the  sacrum.  If  the  bladder  has  not  been  emptied  just  before  the  operation, 
the  urine  is  now  drawn  off  and  about  one  pint  of  tepid  water  injected,  thus  dis- 
tending this  organ  and  rendering  the  mucous  membrane  less  liable  to  injury  from 
being  jDicked  up  by  the  instrument.  The  lithotrite,  having  been  properly  warmed, 
oiled,  and  tested  as  to  its  working  capacity  and  strength,  is  now  prepared  for 
introduction  by  sliding  the  male  blade  completely  down  until  its  tip  passes  into 
the  fenestra  of  the  female  blade.  As  the  convexity  of  the  male  blade  is  serrated, 
great  care  must  be  taken  not  to  push  the  rough  surface  beyond  the  level  of  the 
female  blade,  since  the  introduction  of  the  instrument,  improperly  adjusted,  would 
do  unnecessary  violence  to  the  floor  of  the  urethra. 

A  right-handed  operator  should  stand  at  the  patient's  right  side.  The  instru- 
ment is  locked  and  carried  into  the  bladder  by  the  same  manoeuvres  as  given  for 
the  introduction  of  the  sound  or  metal  catheter.  When  the  beak  is  well  into  the 
bladder,  it  is  carried  along  the  floor,  with  the  tip  pointing  upward,  until  it  meets 
with  the  resistance  of  the  posterior  wall  of  the  bladder,  when  it  should  be  slightly 
withdrawn.  The  handle  should  now  be  elevated,  in  order  to  depress  the  floor 
of  the  bladder  with  the  convexity  of  the  curve.  Held  firmly  in  this  position,  the 
lithotrite  is  opened  by  withdrawing  the  male  blade  about  two  inches.  The  operator 
should  now  strike  the  handle  of  the  instrument  with  the  knuckles  or  hand  hard 
enough  to  carry  the  concussion  to  the  bladder,  in  order  to  dislodge  the  calculus 
and  allow  it  to  fall  into  the  lowest  portion  of  the  organ,  and  within  the  grasp  of 
the  lithotrite,  which  is  now  closed  by  pushing  tlie  male  blade  down.  If  the  stone 
is  seized,  it  will  be  made  evident  by  the  failure  to  close  the  blades,  and,  when 
caught,  it  should  be  firmly  held,  the  screw  movement  adjusted,  and  the  wheel 
rotated  slowly.  Having  thus  secured  the  stone,  the  instrument  should  be  moved 
to  and  fro,  in  order  to  assure  the  operator  that  the  wall  of  the  bladder  is  not 
caught.  In  crushing  a  calculus,  the  rapidity  with  which  it  is  done  should  be  de- 
termined by  the  sense  of  resistance  experienced.  It  is  not  safe  to  employ  force 
sufficient  to  spring  the  blades.  A  stone  which  can  be  safely  crushed  will  yield  per- 
ceptibly under  a  few  turns  of  the  screw.  Phosphatic  stone  can  often  be  rapidly 
comminuted  without  adjusting  the  screw.  Uric-acid  calculi  require  more  power, 
while  the  osalate-of-lime  at  times  cannot  be  crushed  at  all. 

If  the  manoeuvre  above  described  fails  after  being  several  times  carefully  re- 
peated, search  must  be  made  in  other  quarters.  Holding  the  instrument  beak 
upward,  the  convexit\'  still  upon  the  floor  of  the  bladder,  separate  the  blades,  turn 
the  shaft  half  over  to  the  right,  and  then  close  the  blades.  If  the  stone  is  seized, 
hold  it  steady,  adjust  the  screw  motion,  tighten  the  grip  by  a  slight  turn  of  the 
wheel,  and  carry  the  instrument  back  to  the  middle  line  with  the  beak  pointing 
upward.     If  it  does  not  move  freely,  the  indication  is  that  the  bladder  has  been 


THE   BLADDER 


539 


picked  up,  and  of  course  the  blades  must  be  separated  and  another  effort  made. 
"With  the  instrument  shown  there  is  little  danger  of  this  accident.  The  same 
mancKuvre  may  be  tried  on  the  opposite  side.  If  there  is  prostatic  enlargement,  it 
may  be  necessary  to  turn  the  beak  downward  into  the  pocket  on  the  floor  of  the 
bladder.  If,  after  a  half  hour's'  search,  the  seizure  has  not  been  effected,  the 
operation  should  be  discontinued. 

When  the  stone  has  been  seized  and  broken  once,  the  same  manceuvres  should 
be  carefully'  yet  rapidly  repeated  until  no  large  pieces  remain.  It  will  usually  be 
foimd  easy  to  crush  the  smaller  pieces  by  the  sliding  movement  alone.  The  instru- 
ment should  now  be  closed  until  the  blades  have  the  same  relation  as  when  intro- 
duced, and  then  withdrawn.  The  evaciiator  consists  of  a  rubber  bulb  capable  of 
holding  about  one  pint.  At  the  upper  end  is  a  funnel  and  stopcock  for  filling  and 
closing  the  apparatus.  Below  is  attached  a  glass  globe,  in  which  the  particles  of 
stone  gravitate  as  fast  as  they  are  drawn  into  the  evacuator.  Between  this  and 
the  rubber  bulb  is  a  second  stopcock,  and  a  place  for  attaching  the  catheter.  It 
is  advisable  to  insert  a  piece  of  rubber  tubing,  about  five  inches  in  length,  between 
the  catheter  and  the  evacuator,  in  order  to  prevent  the  Jarring  motion  imparted 
to  the  bulb  from  being  conveyed  to  the  instrument  in  the  bladder.  The  catheters 
(Fig.  5-lJ:)  are  of  different  sizes  and  shapes,  ranging  from  No.  14  to  ISTo.  35, 
IJ.  S.  The  evacuation  is  much  more  rapid  with  the  larger  instriunents.  However, 
the  urethra  should  not  be  overdistended.  In  general,  the  catheters  which  are  only 
slightly  curved  near  the  tip,  with  the  eye  at  the  extremity,  are  preferable.  In  filling 
the  bulb,  in  order  to  exclude  the  air,  the  glass  ball  is  first  detached,  filled  with 
clean  warm  water,  and  readjusted.  Both  stopcocks  are  now  open,  the  end  of  the 
tube  closed  with  the  finger,  and  water  poured  into  the  funnel  until  the  bulb  and 
tube  are  filled  to  overflowing.  The  cocks  are  then  closed,  and  the  instrument  en- 
trusted to  an  assistant.  The  catheter,  well  oiled,  is  carried  into  the  bladder,  and 
as  the  water  is  escaping  the  lower  end  of  the 
rubber  tube  attached  to  the  evacuator  is  slipped 
over  the  end  of  the  instrument.  The  bulb  is 
gi'asped  between  the  thumbs  and  fingers  of  both 
hands  and  squeezed,  thus  forcing  the  greater  part 
of  its  contents  into  the  bladder.  It  is  now  allowed 
to  expand ;  the  water  riishes  back  out  of  the  blad- 
der and  brings  with  it  the  smaller  particles  of 
stone  which  fall  down  into  the  glass  sphere.  This 
part  of  the  operation  may  be  expedited  by  rapidly 
half  emptying  the  bulb  into  the  bladder,  and  as 
rapidly  allowing  it  to  expand.  When  it  is  seen 
that  23articles  of  the  calculus  cease  to  fall  into 
the  receiver,  the  catheter  should  be  withdrawn, 
the  lithotrite  reintroduced,  and  a  second  crush- 
ing done.  The  bladder  is  again  washed  out,  and 
these  operations  should  be  alternated  until  all 
detritus  is  removed,  im.less  alarming  sjTujJtoms 
should  supervene,  when  of  course  all  operative 
measures  should  be  discontinued.  If  the  glass 
receiver  becomes  filled,  it  should  be  detached  and 
emptied.  At  times  particles  of  calculus  become 
lodged  in  the  catheter  or  tube,  and  require  to  be 
dislodged  with  a  stylet.  From  one  to  one  and  a 
half  hours  may  be  allowed  for  this  operation  from 
the  commencement  of  the  anaesthesia.  The  prog- 
nosis   will   be   more   favorable   with   the   shorter 

period,  but  it  is  wiser  to  proceed  carefully  and  remove  the  stone  thoroughlj^,  even  if 
a  longer  time  is  required.  The  absence  of  all  fragments  can  be  recognized  by  plac- 
ing the  ear  over  the  bladder  at  the  symphysis  while  the  evacuator  is  being  worked. 
The  click  of  any  fragments  against  the  catheter  can  be  distinctly  heard.  The 
introduction  of  a  sound  will  also  determine  the  presence  of  any  pieces. 


Fig.  544. — Thompson's  improved  evac- 
uator and  catheters. 


540  THE   BLADDER 

In  the  after-treatment  opium  is  essential  to  relieve  pain  and  tenesmus.  Citrate 
of  potash,  grs.  xx,  three  or  four  times  a  day,  with  flaxseed  tea,  will  render  the  urine 
less  irritating.    The  soft  catheter  may  need  to  be  employed  to  evacuate  the  bladder. 

In  incomplete  lithotrity  the  crushing  is  done  in  the  same  manner  as  just  de- 
scribed. A  fair  degree  of  urethral  anaesthesia  may  be  secured  by  the  employment 
of  cocaine.  The  lithotrite  is  only  introduced  once,  and  not  more  than  five  or 
ten  minutes  are  -consumed  in  the  operation.  The  evaeuator  is  not  employed,  the 
detritus  being  ex]Delled  in  the  act  of  urination. 

Cystotomy  or  Lithotomy. — Cutting  into  the  bladder  for  the  removal  of  stone 
is  performed  through  the  perinseum  or  through  the  abdominal  wall,  Just  above 
the  symphysis  pubis.  Incision  through  the  rectum  in  males  is  no  longer  a  recog- 
nized procedure,  while  the  vesico-vaginal  operation  is  rarely,  if  ever,  indicated, 
since  it  necessitates  a  second  operation  to  close  the  fistula. 

Suprapubic  cystotomy  is  such  a  safe  and  simple  procedure  that  it  should  be 
preferred  to  perineal  cystotomy  in  practically  all  cases  in  which  entrance  to  the 
bladder  by  an  operative  wound  is  desired.  For  the  removal  of  all  forms  of  neo- 
plasm not  involving  the  prostate,  no  other  method  is  to  be  compared  to  it.  For 
the  extraction  of  foreign  bodies  so  shaped  or  so  large  that  they  cannot  be  with- 
drawn by  means  of  the  small  Thompson  lithotrite  without  undue  violence  to  the 
urethral  canal  it  is  to  be  preferred.  It  is  the  better  operation  in  all  cases  of  vesical 
calculus,  with  the  exception  of  very  small  and  soft  calculi  in  adults  in  whom  the 
urethra  is  capable  of  freely  admitting  the  lithotrite  and  the  bladder  is  not  affected 
with  marked  cystitis.  Under  such  conditions,  in  expert  hands,  litholapaxy  is  per- 
missible, the  fragments  being  removed  either  by  the  act  of  urination  or  with 
the  evaeuator.  In  all  forms  of  cystitis  due  to  prostatic  hypertrophy  the  perineal 
operation  cannot  be  compared  to  the  suprapubic  incision.  In  females  it  should 
absolutely  supersede  the  establishment  of  a  vesico-vaginal  fistula,  for,  with  proper 
care,  a  perfectly  satisfactory  drainage  and  rest  to  the  bladder  can  be  obtained  by 
suprapubic  siphonage,  a  method  which  will  not  only  cure  the  cystitis,  but  saves 
the  patient  from  a  secondary  and  formidable  operation  in  the  closure  of  a  vesico- 
vaginal fistula. 

Operation. — It  is  important  not  only  to  shave  those  parts  in  the  immediate 
field  of  operation,  but  the  perinseum,  the  inner  surface  of  the  thighs,  and  the 
region  of  the  anus  and  buttocks.  It  is  almost  impossible  to  prevent  an  occasional 
overflow  of  urine  in  the  after-treatment,  and  if  the  hairs  are  all  removed  the 
parts  can  be  mi;ch  more  readily  cleansed  and  unpleasant  odors  prevented.  The 
patient  should  rest  upon  the  back,  with  the  legs  in  full  extension  and  upon  a 
table  so  constructed  that,  at  the  proper  moment,  a  modified  Trendelenburg  pos- 
ture may  be  secured.  The  full  Trendelenburg  is  not  desirable,  but,  if  the  pelvis 
can  be  lifted  a  foot  above  the  level  of  the  shoulders,  the  weight  of  the  intestines 
will  be  taken  off  the  bladder,  which  is  an  advantage.  There  is  no  necessity  under 
any  circumstances  to  use  rectal  distention.  For  dilating  the  bladder,  I  prefer 
water.  I  employ  a  soft  catheter  and  a  glass-barreled  syringe  containing  four  ounces 
of  warm  salt  solution,  or  water  which  has  been  boiled  and  cooled  to  about  110°  F. 
From  twelve  to  sixteen  ounces  are  forced  into  the  bladder,  and  in  males  this  can 
be  held  in  by  tying  rubber  tubing  around  the  urethra  and  catheter,  in  females 
by  digital  pressure  upon  the  urethra  from  below  upward  against  the  arch  of  the 
pubis.  The  incision  I  prefer  is  the  longitudinal,  the  lowest  angle  of  which  is 
one  inch  below  the  upper  margin  of  the  symphysis  pubis  and  the  upper  angle  about 
three  inches  above  this  bone.  Separating  the  muscles  in  the  median  line,  all  haem- 
orrhage should  be  arrested  as  the  operation  proceeds.  With  dull-pointed,  curved 
scissors,  the  insertion  of  the  recti  muscles  are  snipped  away  for  from  one  fourth 
to  three  fourths  of  an  inch  on  either  side  of  the  median  line  close  to  their  attach- 
ment to  the  pubic  bone.  If  the  operation  is  for  the  removal  of  a  stone  of  small 
size  or  a  foreign  body,  or  for  exploration  or  drainage  in  uncomplicated  cystitis, 
it  is  not  essential  to  have  a  wide  external  wound  or  a  large  incision  into  the 
bladder.  I  therefore  modify  the  incision  and  exposure  of  this  organ  as  the  opera- 
tion may  require.  When  there  is  a  tumor,  as  the  greatest  possible  room  is  re- 
quired, I  usually  add  to  the  longitudinal  a  short  transverse  incision  parallel  with 


THE   BLADDER 


541 


the  pubic  crest,  which  divides  or  nicks  tlie  sheath  of  the  recti  and  permits  a  free 
retraction  of  the  uncut  muscle.  When  these  muscles  are  held  back  with  retractors, 
the  loose  areolar  tissue  situated  between  the  bladder  and  the  surface  of  the  pubic 
bone  and  the  abdominal  muscles  is  readily  seen  and  separated  from  its  slight 
attachment  to  the  bone.  If,  then,  the  finger  is  carried  down  with  the  dorsum  in 
contact  with  the  surface  of  the  pubic  symphysis,  this  prevesical  fat  can  be  easily 
detached  from  the  bladder  with  the  blunt  scissors  as  a  dissector,  and  carried  up- 
ward for  a  distance  of  from  one  and  a  half  to  two  inches,  and,  in  certain  cases 
of  tumor  of  the  upper  posterior  wall  of  the  bladder,  the  peritoneum  may  be  still 
further  dissected  off  by  lifting  the  prevesical  fat  and  carrying  the  peritonffiura 
up  with  it.  However,  the  peritouEeum  is  rarely  seen.  If  torn  through  or  incised 
it  should  be  immediately  sutured  with  catgut.  If  at  this  stage  of  the  operation 
it  is  evident  that  the  bladder  is  not  sufficiently  distended  to  bring  it  well  under 
the  touch  of  the  surgeon  or  to  lift  the  peritonteum  high  enough,  four  or  eight 
ounces  more  of  the  fluid  may  be  injected  through  the  catheter,  which  has  been  left 
in.  When  a  tumor  is  to  be  removed,  or  a  stone  of  large  size,  requiring  a  good  deal 
of  operative  interference  within  this  organ,  before  opening  the  bladder  I  usually 
insert  two  loops  of  silk  thread,  which  are  carried  by  means  of  a  short  curved  liage- 
dorn  needle  entirely  through  the  bladder  wall,  one  on  either  side  of  the  proposed 
line  of  incision.  A  little  fluid  will  escape  through  these  punctures,  but  will  not 
interfere  with  the  operation.  These  loops  are  left  long  and  tied  at  least  a  foot  from 
the  margin  of  the  incision,  and  are  intended  to  steady  the  anterior  wall  of  the 
bladder  by  proper  traction  as  the  operator  is  at  work  within  the  bladder.  In  this 
way  undue  dissection  of  the  anterior  liladder  wall  from  its  normal  attachments  can 
be  prevented.  In  rare  instances,  where  one  or  more  large  veins  appear  on  the 
anterior  wall,  if  a  line  of  incision  cannot  be  secured  to  one  side  and  safely  removed 
from  these  veins,  catgut  ligature  should  be  passed,  by  means  of  a  short-curved 
needle,  and  the  vessels  secured  and  divided  between  the  ligatures.  In  removing 
tumors  it  is  very  important  to  have  a  large  incision  through  the  bladder  wall,  and 
to  dilate  this  widely  in  all  directions  by  retractors  so  inserted  that  the  cavity  of 
the  bladder  is  well  exposed  and  the  point  of  attachment  of  the  tumor  brought  in 
sight.  In  removing  papillomata  they  can  usually  be  scraped  off  with  the  finger 
nail  or  an  ordinary  uterine  curette.  The  point  of  attachment  should  then  be 
thoroughly  burned  with  the  blunt  Paquelin  cautery.  For  small  hypertrophies  of 
the  middle  lobe  of  the  prostate,  no  other  portion  of  this  organ  being  materially 
involved,  it  is  not  so  essential  to  have  the  tumor  exposed,  since  the  cutting  forceps 
can  be  applied  directly  by  the  sense  of  touch,  placing  the  tip  of  the  index-finger 
upon  the  mass  to  be  removed,  and  carrying  the  forceps  down  with  one  blade  on 
each  side  of  the  finger  until  the  blades  are  guided  on  to  the  mass.  The  forceps 
I  have  had  made  for  this  purpose  have  double  cup-shaped  blades,  which,  when 
the  tumor  is  seized,  are  closed  but  do  not  entirely  cut  off  the  section  grasped. 


Fig.  545. — The  author's  forceps  for 


ing  tumors  of  the  prostate  and  bladder. 


The  removal  is  made  by  twisting,  in  order  to  prevent  the  heemorrhage  which 
would  result  from  a  clean  cut  of  these  hard  tumors.  When  any  well-marked 
hiBmorrhage  is  present,  hot-water  irrigation  will  aid  in  controlling  it.  I  have 
on  no  occasion  had  to  pack  the  bladder  for  haemorrhage,  but  would  not  hesitate 
to  do  this  if  necessary.     In  operating  for  the  removal  of  foreign  bodies,  a  much 


542 


THE   BLADDER 


smaller  incision  is  required,  and  for  small  calculi  an  incision  an  inch  long  in  the 
bladder  will  suffice.  I  have  found  it  much  easier  to  remove  these  stones  by  slip- 
ping them  along  with  the  index-finger  until  they  present  at  the  wound  in  the 
bladder.  My  objection  to  using  an  instrument  for  removing  calculi  is  the  fear 
of  breaking  ofi:  small  23artieles  which  may  escape  detection  and  remain  in  the 
bladder.  I  have  never  had  any  trouble  in  extracting  stones  in  this  manner.  In 
one  instance,  where  more  than  one  hundred  were  removed,  I  used  a  good-sized 
bladder  scoop,  as  it  expedited  the  operation. 

The  after-treatment  of  these  cases  must,  of  course,  vary.  When  there  is  no 
well-marked  inflammation  of  the  bladder,  as  after  removal  of  a  small  stone  or 
tumor  or  foreign  body,  or  after  exploration  of  the  bladder  in  which  no  lesion  was 
found,  the  operator  may  close  the  bladder  by  immediate  suture.  This  is  a  very 
desirable  method,  for  the  reason  that  it  does  away  with  the  necessity  for  supra- 
pubic drainage  and  the  slow  process  of  closure  of  the  wound,  which,  if  left  alone, 
takes  from  two  to  three  weeks.  In  closing  the  bladder,  I  prefer  firm  small  ehromi- 
cized  catgut,  and  the  suture  used  is  not  unlike  the  Lembert 
suture  employed  in  intestinal  surgery.  The  needle  is  inserted 
about  one  eighth  of  an  inch  from  the  cut  edge  and  comes 
out  near  the  edge,  j^et  not  upon  the  cut  surface,  nor  does 
the  needle  go  into  the  cavity  of  the  bladder.  The  sutures 
should  be  about  one  sixteenth  of  an  inch  apart.  It  is  not 
safe  to  close  the  superficial  wound  over  this  line  of  sutures. 
A  liglit  packing  of  gauze  will  sufiice. 

When  the  bladder  is  closed  a  catheter  should  be  inserted 
and  allowed  to  remain  in  for  three  days  after  the  operation, 
or  the  water  should  be  drawn  by  catheter  every  three  or  four 
hours  in  order  to  prevent  aiij  distention  of  the  organ  or 
strain  upon  the  sutures.  If  for  any  reason  the  surgeon 
should  deem  it  best  not  to  undertake  immediate  suture  of 
the  bladder,  he  may  rest  assured  that  in  from  three  to  four 
weeks  the  wound  will  close  by  the  ordinary  process  of  repair 
in  practically  all  eases. 

In  drainage,  the  use  of  the  rubber  tube  is  essential  for 
the  comfort  of  the  patient.  The  ordinary  T-shaped  Tren- 
delenburg tube  is  very  unsatisfactory.  Dr.  J.  A.  Bodine  has 
modified  this  by  extending  that  part  of  the  tube  which  jjro- 
jects  into  the  bladder  at  least  four  and  a  half  inches  beyond 
the  crosspiece,  which  is  intended  to  catch  within  the  bladder 
on  either  side  of  the  incision  in  this  organ.  As  the  end  of 
the  tube  is  thus  kept  in  the  deepest  portion  of  the  bladder, 
the  siphonage  is  more  satisfactory.  After  the  tube  is  intro- 
duced and  before  the  wound  is  closed,  it  is  better  to  throw 
in  a  good  quantity  of  warm  salt  solution  in  order  to  flush 
the  bladder  and  wash  out  any  clots  which  may  have  been 
overlooked.  The  wound  may  be  partially  closed  by  one  or 
two  superficial  sutures  in  the  upper  and  lower  angles,  or  left 
entirely  open  and  filled  with  a  light  packing  of  gauze  around 
the  tube.  The  duration  of  drainage  should  be  determined 
by  the  condition  of  the  bladder.  After  the  removal  of  a 
tumor  or  stone  uncomplicated  with  severe  chronic  cystitis, 
the  tube  may  be  removed  in  five  or  six  days.  In  five  or  six 
more  a  portion  of  the  urine  will  be  discharged  through  the  urethra,  and  entirely 
by  this  route  in  ten  days  or  two  weeks  more. 

Since  there  is  usually  danger  of  overflow  due  to  obstruction  of  the  tube  from 
blood  clot  during  the  first  twenty-four  hours  after  the  operation,  a  generous 
quantity  of  absorbent  cotton  should  be  placed  around  and  over  the  wound.  When 
the  tube  is  placed  in  position,  it  is  attached  to  a  long  piece  of  tubing  which  is 
carried  down  the  side  of  the  bed  and  held  in  place  by  safety  pins,  and  through 
this  the  urine  is  carried  into  a  receiDtacle  f)laced  to  receive  it.     Siphonage  may  be 


Fig.  546. — Bodine'smod- 
ification  of  Trendelen- 
burg's T-tube. 


THE   BLADDER 


543 


started  bj'  injecting  the  solution  into  tlie  long  tube  until  the  bladder  is  well  filled, 
holding  the  end  of  the  tube  higher  than  the  summit  of  the  bladder,  removing  the 
S3Tinge,  and  closing  the  tube  by  pressure  of  the  finger:  the  end  is  brought  down 
lower  than  the  level  of  the  bladder,  the  pressure  released,  and  the  fluid  allowed  to 
run  out  of  the  tube,  thus  establishing  siphonage.  The  danger  of  infiltration  of 
urine  between  the  bladder  and  the  abdominal  wall  or  the  pelvic  bones  is  not  to  be 
considered  when  the  abdominal  incision  is  open  and  loosely  packed. 

Perineal  lithotomy  is  now  rarely  performed,  and  should  only  be  undertaken 
when  the  conditions  are  such  that  perineal  drainage  is  essential.  When  necessary 
tlie  operation  of  choice  is  the  median  or  the  combination  known  as  the  medio-lateral. 
Median  lithotomy  or  perineal  section  is  performed  as  follows: 
Two  hours  before  the  operation  the  rectum  should  be  emptied  by  a  free  enema 
of  tepid  water,  and  the  perinajum  cleanly  shaved.  The  patient  should  be  placed 
upon  the  back,  the  sacrum  resting  near  the  edge  of  the  table,  the  thighs  flexed 
toward  the  abdomen,  slightly  abducted,  the  feet  brought  down  and  secured  to  the 
hands  and  wrists  by  several  turns  of  a  roller.  Each  leg  is  entrusted  to  an  assistant, 
while  a  third,  selected  for  his  special  fitness,  and  upon  whom  the  duty  of  holding 
the  guide  devolves,  stands  beside  the  patient's  abdomen,  facing  the  operator. 


a.TIEI^IANN  a  CO 


Fig.  547. — Little's  lithotomy  staff. 


If  the  bladder  is  not  fairly  distended  with  urine,  a  Nekton's  catheter  should 
be  introduced,  and  about  a  pint  of  fluid  injected.  Little's  guide,  grooved  in  the 
middle  (Fig.  547),  is  next  carried  into  the  bladder.  The  probabilities  are  that 
the  stone  will  be  felt  by  the  sound.  If  the  calculus  has  been  recognized  within  a 
day  or  two,  and  if  in  the  meantime  the  urine  has  been  carefully  watched  and  no 
solid  substance  has  escaped  by  the  urethra,  no  prolonged  effort  should  be  made 
at  this  juncture  to  demonstrate  its  presence. 

The  proper  position  for  the  guide  is  shown  in  Fig.  548.  The  shaft  is  held 
in  such  a  position  that  the  stafE  is  perpendicular  to  the  plane  of  the  body,  the 


Fig.  548. — Guide  in  position.      (After  Bryant.) 

tip  well  in  the  bladder,  with  the  convexity  of  the  instrument  pressing  firmly  and 
steadily  toward  the  perinasum.    The  finger  is  now  carried  into  the  rectum  in  order 


544 


THE   BLADDER 


to  guard  against  puncture  of  the  anterior  wall  of  this  organ.  Little's  lithotomy- 
knife  is  entered  Just  about  one  half  inch  anterior  to  the  anus  in  the  median  line,  the 
edge  of  the  blade  directed  upward,  and  is  pushed  straight  inward  until  the  point 
strikes  into  the  concavity  of  the  groove  in  the  staff  at  the  anterior  limit  of  the 
prostate.     It  is  then  made  to   cut  forward   and  upward  until   the  membranous 


Fig.  549. — Lithotomy  forceps. 


portion  is  divided,  and,  as  it  is  withdra-mi,  the  incision  in  the  perinreum  is  length- 
ened in  all  about  one  and  a  half  inches.  The  finger  is  now  introduced,  the  sound 
withdrawn,  and  the  wound,  prostatic  portion  of  the  urethra,  and  neck  of  the  blad- 
der dilated  until  the  stone  can  be  felt  and  extracted  with  a  slender  forceps. 

The   forceps    (Fig.    549)    should  now  be  introduced   and  the   stone  removed. 
This  instrument  cannot  always  be  carried  in  through  the  wound  if  the  finger  is 


Fig.  550. — Scoop  and  conductor. 

allowed  to  remain,  and  is  at  times  difficult  of  introduction  without  a  guide.  To 
prevent  delay,  the  conductor  (Fig.  550)  should  be  passed  along  the  finger  into 
the  bladder  and  allowed  to  remain  after  the  finger  is  withdrawn.  If  the  blades 
of  the  forceps  are  now  closed  upon  the  flange  of  the  conductor,  the  instrument 


Fig.   551. — Lithotomy  scoop. 

can  be  made  to  slide  accurately  along  the  guide  into  the  bladder,  after  which  the 
conductor  should  be  removed. 

In  removing  a  stone  with  the  forceps  two  precautions  are  essential:  (1)  not 
to  pick  up  the  wall  of  the  bladder  with  the  calculus,  and  (2)  not  to  employ  force 
enough  in  grasping  the  stone  to  critsh  it. 

When  the  stone  is  grasped,  if  the  instrument  can  be  moved  freely  within  the 
bladder,  it  is  evident  that  this  organ  is  not  caught. 

With  small  calculi  the  extraction  is  easily  accomplished.  When  the  stone  is 
large,  a  certain  amount  of  force  is  justifiable  and  necessary  to  stretch  the  wound 
to  its  utmost;  but  this  force  should  never  be  used  unless  the  operator  is  satisfied 
that  the  stone  and  jaws  of  the  forceps  can  be  brought  through  the  wound  without 
serious  injury  to  the  bladder  and  prostate.  If  the  stone  cannot  be  extracted  whole, 
it  would  be  safer  to  make  a  suprapubic  opening  rather  than  crush  it  into  frag- 
ments. Finally,  a  sound  should  be  introduced  and  search  made  for  a  second  stone 
lodged  in  the  more  remote  portions  of  the  bladder. 

Among  the  accidents  which  may  complicate  perineal  lithotom}^  in  addition  to 
that  of  wounding  the  rectum,  is  haemorrhage  from  the  artery  of  the  bulb  and 
other  vessels  of  the  perineum.  The  ligature  will  control  all  superficial  bleeding, 
and,  should  a  deep  vessel  be  divided,  it  may  be  transfixed  with  a  tenaculum  and  . 
tied,  or  the  hook  allowed  to  remain  in  the  wound  for  a  day  or  two.  If  the  oozing 
is  free  and  general,  an  umbrella  compress  (Fig.  552)  should  be  made  by  tying 
a  piece  of  oiled  silk  or  rubber  tissue  to  a  canula  or  bougie.  This  is  carried  into 
the  wound  and  compression  made  by  packing  sponges  beneath  the  cloth  which  is 
brought  in  contact  with  the  bleeding  surface. 


THE   BLADDER 


545 


The  after-treatment  of  median  or  medio-lateral  lithotomy  is  simple.  The  ■^vound 
is  left  open  and  unmolested.  The  urine  passes  through  this  for  a  few  days  or 
weeks,  and  ffraduallv  resumes  the  iirethral  channel  as  the  incision  closes  bv  sranu- 


FiG.  552. — Umbrella  compres 


lation.     In  some- eases  the  urine  passes  through  the  urethra  uninterruptedly.     The 
patient  should  remain  in  bed  for  two  or  three  weeks. 

The   anatomical  relations  of  the  parts  involved  in  this  operation  are   shown 
in  Fig.  553. 


Tig.  553. — A,  B.  Bulbous  portion  •  if  'In;  iirt  t'lira.  C,  Right  lateral  lobe  of  the  prostate,  il,  Junction  of 
bulbous  and  prostatic  portions  oi  tlie  urethra.  The  line  of  section  in  median  lithotomy  extends  from 
A  to  M.  Should  the  necessity  arise  this  incision  maj'  be  extended  obliquely  along  the  dark  line. 
D,  Corpus  cavemosum.  F,  Rectum.  A',  Vesicula  seminalis.  Q,  Vas  Deferens.  L,  Arterj-  of  the 
bulb,     (.\fter  Maclise.) 

Sione  in  the  Bladder  of  Females. — ^Vesical  calculi  are  not  met  with  in  females 
a?  frequently  as  in  males,  ilany  conditions  which  conduce  to  the  lodgment  or 
formation  of  stone  in  the  male  bladder,  and  are  common  in  this  sex,  are  either 
impossible  to,  or  rarely  occur  in,  females. 

Another  explanation  of  the  comparative  infrequeney  of  stone  in  females  is 
the  short  and  dilatable  urethra,  allowing  the  escape  of  many  small  concretions 
which  in  men  would  lodge  in  the  eul-de-sac  behind  the  prostate.     Tlie  svmptoms 


546 


THE   BLADDER 


do  not  differ  from  those  given  in  stone  in  tlie  bladders  of  males.  The  diagnosis 
rests  iijDon  exploration  with  a  searcher,  combined  with  digital  exploration  per 
vaginam,  and  direct  pressure  over  the  pubes. 

Treatment. — Small  calculi  found  in  the  bladders  of  females  may  be  readily 
removed  by  lithotrity.  The  short  and  distensible  urethra  permits  of  the  intro- 
duction of  the  largest  evacuating  catheter,  and  greatly  facilitates  the  operation. 
The  older  method  of  dilatation  or  divulsion  of  the  urethra  and  extraction  in  mass 
by  forceps  is  not  justifiable.  Large  calculi  and  small  oxalate-of-lime  concretions, 
which  may  not  be  easily  and  completely  crushed,  shorild  be  removed  by  the  supra- 
pubic operation.  Incision  through  the  vesico-vaginal  septum  requires  a  second 
operation  for  its  closure,  and  of  itself  is  more  complicated  than  the  suprapubic 
method.^ 

Foreign  Bodies. — Foreign  substances  in  the  bladder  are  usually  introduced 
through  the  urethra.  Less  frequently  they  pass  through  the  walls  of  this  organ, 
as  in  gunshot  wounds,  etc.  In  exceptional  instances  foreign  matter  finds  its  way 
into  the  bladder  through  a  fecal  or  vaginal  fistula.  Pus  in  a  number  of  cases  of 
appendicitis  has  found  its  way  into  this  organ.  In  several  cases  of  this  character 
worms  have  escaped  from  the  intestines  and  found  an  exit  through  the  urethra. 

The  symptoms  are  usually  those  of  stone  in  the  bladder,  with  cystitis  in  a 
varying  degree.  The  diagnosis  may  be  evident  from  the  history  of  an  accidental 
or  intentional  introduction  of  the  foreign  substance.  The  matter  can  usually  be 
recognized  by  the  searcher.  If  a  few  weeks  have  elapsed,  the  foreign  body  will 
probably  be  coated  with  a  deposit  of  urinary  salts,  and  will  impart  to  the  sound 
the  grating  or  click  peculiar  to  stone. 

The  treatment  consists  in  removal  of  the  offending  substance  as  soon  as  pos- 
sible. If  it  is  small,  round,  and  smooth,  it  may  be  extracted  through  the  urethra 
with  the  lithotrite.  For  this  purpose  the  smallest  instrument  should  be  employed. 
If  it  is  too  large  to  be  brought  out  in  mass,  it  may  be  chopped  up  or  crushed. 


and  then  extracted  j)iecemeal,  in  the  jaws  of  the  lithotrite,  or  washed  out  through 
the  evacuator.  Fig.  554  represents  an  English  gum  catheter  which  was  removed 
in  this  manner.  The  two  larger  pieces  were  grasped  by  the  end  and  drawn  out ; 
the  remainder  was  caught  in  the  lithotrite,  and  brought  out  one  piece  at  a  time. 

When  the  substance  is  so  large  or  of  such  a  shape  that  it  cannot  with  safety  be 
brought  through  the  urethra,  cystotomy  is  imjjerative. 

1  Prof.  George  Ben  Johnston,  of  Rrchmond,  Va.,  from  a  careful  study  of  this  subject,  concludes 
that  stone  is  4.72  per  centum  more  prevalent  in  whites  than  in  negroes  in  the  United  States. 


CHAPTER    XXIX 

THE       PROSTATE PROSTATITIS HYPERTROPPIY PROSTATECTOMY PEEMAKENT 

DRAINAGE  SPERilATORRHCEA  PROSTATORRHfEA  ASPERMATISM  TUBER- 
CULOSIS   CARCINOMA SARCOMA CONCRETIONS  —  NEURALGIA SEMINAL 

VESICLES fuller's    OPERATION 

The  Prostate  Bodij. — Disease  of  the  prostate  is  almost  always  a  condition  of 
adult  life.  This  organ  is  rudimentary  in  childhood,  and  while,  from  direct  injury, 
as  in  catheterization,  lithotomy,  or  any  form  of  violence,  or  by  the  extension  of 
any  of  the  rarer  forms  of  disease  which  afEect  the  bladder  or  urethra  of  children, 
this  body  maj^  be  involved,  it  only  assumes  its  true  importance  after  it  has  taken 
on  its  functional  activity. 

Prostatitis. — Inflammation  of  the  prostate  may  be  partial  or  comj)lete,  as  well 
as  acute  or  chronic.  It  may  afEect  the  epithelial  and  glandular  or  muscular  and 
connective-tissue  structure  of  this  complex  organ.  Prostatitis  rarely  originates 
in  the  substance  of  this  bod}^  which  is  usually  involved  by  the  extension  of  an 
inflammation  from  the  bladder,  urethra,  or  other  organs  and  tissues  in  its  imme- 
diate neighborhood.  Urethritis,  cystitis,  epididymitis,  and  proctitis  are  among  the 
more  common  causes.  To  these  majf  be  added  excessive  venereal  excitement,  all 
forms  of  traumatism,  whether  by  violence  applied  to  the  rectal  or  perineal  regions, 
or  by  instruments  in  the  urethra,  and  the  presence  of  calcareous  or  amylaceous 
concretions. 

The  sympioms  are  usually  well  marked.  Pain  in  the  acute  form  of  inflam- 
mation is  usually  intense  and  burning  in  character.  There  is  a  sense  of  fullness 
and  throbbing  in  the  organ.  With  the  finger  in  the  rectum  the  enlargement  may 
be  appreciated,  together  with  abnormal  heat  and  throljljing  of  the  arteries.  Pain 
is  increased  by  direct  pressure  in  the  perinajum  or  rectum,  and  also  in  the  act 
of  urination.  Fever  is  present  in  proportion  to  the  severity  of  the  local  process. 
Suppuration  and  the  formation  of  an  abscess  are  usually  indicated  by  exacerba- 
tions of  temperature  and  by  interference  with  micturition. 

The  first  indication  in  the  treatment  of  this  painful  affection  is  rest  in  the 
recumbent  posture.  The  bowels  should  be  kept  open.  The  ice-bag  to  the  peri- 
neum will  be  found  of  value.  If  retention  of  urine  occurs,  it  should  be  relieved 
by  the  use  of  the  smaller  soft  catheter.  Suprapubic  aspiration  may  be  demanded 
in  severe  cases.  Scarification  of  the  perinseum  and  the  application  of  cups  are 
highly  recommended  as  local  measures.  If  abscess  exists,  it  should  be  evacuated 
by  the  aspirator  or  incision  through  the  perinseum.  Eupture  may  occur  into  the 
urethra,  or  the  abscess  may  find  an  opening  through  the  perinseum  or  rectum. 

Ilypertropliy. — Chronic  progressive  enlargement  of  the  prostate  occurs  in  about 
one  third  of  all  males  who  live  through  the  period  from  fifty  to  seventy-five  years 
of  age.  The  increase  in  volume  is  not  a  true  hyperplasia,  for  the  glandular  func- 
tions, as  well  as  the  muscular  power  of  the  organ,  decrease  with  the  hypertrophy. 
In  some  portions  of  the  mass  the  muscular  tissue  is  increased,  but  the  bulk  of 
the  enlargement  is  due  to  the  presence  of  newly  formed  connective  tissue.  The 
induration  is  in  proportion  to  the  excess  of  the  new  tissue  over  the  normal  mus- 
cular and  glandular  elements.  In  some  instances,  though  rarely,  the  glandular 
elements  are  increased;  but  this  is,  in  all  probability,  only  observed  in  the  earlier 
stages  of  hypertrophy,  before  the  connective-tissue  elements  are  in  sufficient  quan- 
tity to  cause  atrophy  of  the  glandular  apparatus.     The  enlargement  may  be  local 

547 


548 


THE   PROSTATE 


or  o-eneral.  In  general  hj'pertroph)-,  ^vhile  the  increase  in  size  is  in  all  directions, 
it  is  more  marked  in  the  posterior  portions,  where  it  encroaches  upon  the  neck 
of  the  bladder.    Not  infrequently  one  lateral  lobe  is  greatly  enlarged,  or  the  hj^per- 


FiG.  555. — Longitudinal  section  of  hypertrophied  prostate  in  a  patient  seventy-four  years  of  age,  show- 
ing a  false  passage  tunneled  by  a'  catlieter.  b,  Line  of  tran.sverse  section  shown  in  Fig.  556.  a,  Duct 
of  vesicula  seminalis.     (A'fter  Socin.) 


trophy  may  be  central,  resulting  in  the  development  of  a  middle  or  third  lobe, 

which,  by  progressive  enlargement,  not  only  changes  the  axis  of  the  normal  urethra, 

but  occludes,  in  a  variable  degree,  the 

outlet  of  the  bladder.    This  last  coudi-  ^gg^^ 

tion  is  well  shown  in  Fig.  555,  and  that  V"^^^^\ 


!FlG.  556. — Transverse  section  through  the  center 
of  the  prostate  of  a  patient  seventy-four  years 
old.  Hypertrophy  of  fourteen  years'  duration. 
a,  Urethra,  b,  Caput  gallinaginis.  (After 
Socin.) 


Fig.  557. — Showing  the  relations  of  the  floor  of 
the  bladder  to  the  prostatic  urethra  in  the 
normal  condition  of  this  body.  The  bristle  is 
passed  from  the  ejaculatory  duct  into  the 
urethra.     (After  Socin.) 


of  general  hypertrophy  of  the  muscular,  fibrou.s,  and  glandular  tissues,  with  nar- 
rowing of  the  urethra,  in  Pig.  556. 

Symptoms. — The  increase  in  size  is  usually  so  gradual  that  the  condition  of , 
hypertrophy  does  not  attract  the  attention  of  the  patient  until  interference  with- 
the  flow  of  urine  occurs.  As  a  result  of  retention  the  bladder  is  distended,  the 
contractility  of  its  muscular  walls  is  diminished,  and  chronic  cystitis  inevitably 


THE  PROSTATE 


549 


ensues.  The  changes  which  take  place  in  this  organ — thickening  of  the  walls, 
occasional  sacculation,  the  formation  of  calculi,  dilatation  of  the  ureters,  etc. — 
have  been  given.  In  severe  cases  the  functions  of  the  rectum  may  be  interfered 
with. 


Fig.  55S. — Hj'pertrophy  of  the  prostate,  showing  the  asymmetrical  development  of  the  middle  or  third 
lobe,     a,  a,  Openings  of  ureters.     (After  Socin.) 

The  diagnosis  may  be  determined  by  the  presence  of  the  symptoms  just  given, 
by  digital  exploration  per  rectum,  and  by  the  introduction  of  a  sound  or  bougie 
through  the  urethra. 

The  treatment  is  palliative  and  operative.  When  recognized  early  in  its  his- 
tory, every  source  of  irritation  should  be  removed  from  this  organ.  The  bowels 
should  be  kept  open,  the  irritability  of  the  urine  diminished  by  the  administration 
of  alkaline  diluents,   and  all  venereal   excitement  prohibited.     In  those   affected 


Fig.  559. — Antero-posterior  section  of  the  same  specimen. 


with  gout  or  rheumatism,  or  any  disturbance  of  the  digestive  apparatus,  judicious 
diet  and  medication  may  arrest,  or  at  least  retard,  the  progress  of  the  disease  in 
the  prostate. 

When,  however,  the  obstruction  to  the  outflow  of  urine  is  such  that  hyperdis- 
tention  of  the  bladder  is  taking  place,  together  with  cystitis  resulting  from  de- 
composition of  that  portion   of  the  bladder   contents  which  cannot  be  expelled, 


550 


THE   PROSTATE 


prostatectoviy  should  be  advised.  This  operation  is  a  valualjle  contribution  to  the 
surgery  of  the  male  geni to-urinary  organs^  and  when  properly  done  in  the  earlier 
stages  of  hypertrophy,  before  the  pathological  changes  in  the  bladder  have  affected 
the  ureters  and  the  kidneys  by  direct  or  ascending  infection,  the  mortality  is 
insigniticant. 

Prostatectomy. — The  prostate  may  be  removed  by  either  the  suprapubic  or  the 
perineal  incision,  and  under  certain  conditions  it  may  be  advisable  to  utilize  both 
of  these  approaches.  In  very  rare  instances,  when  the  obstruction  to  the  outflow  of 
urine  is  due  almost  if  not  wholly  to  a  hypertrophy  of  what  is  known  as  the  third 
or  middle  lobe  of  this  organ,  this  hypertrophied  portion  may  alone  require  removal. 
In  this  minor  procedure,  the  suprapubic  incision  should  be  preferred,  through 
which  the  obstruction  to  the  escape  of  urine  may  be  easily  removed  by  the  author's 
prostatic  forceps,  as  heretofore  given    (Fig.   515).      Suprapubic  drainage  will  be 


WW 


,  560. — The  normal  urethra  of  the  male  adult.      I-rom  a  frozen  section. 
(After  Braune.) 


Reduced  from  life  size. 


necessary  for  a  few  days,  after  which  the  bladder  incision  may  be  left  to  close 
b}^  granulation. 

The  suprapubic  route  should  also  be  favoraljly  considered  when  there  is  a 
general  enlargement  of  the  prostate  with  marked  projection  of  the  hypertrophied 
portion  into  the  lumen  of  the  bladder,  as  shown  in  Fig.  555.  In  some  of  the 
enormous  hypertrophies,  which  are  occasionally  observed,  it  may  be  necessary  to 
combine  the  perineal  route  with  the  suprapubic.  In  working  from  above,  the 
mucous  membrane  covering  the  bulging  prostate  should  be  torn  through  b}''  the 
dull-pointed  scissors  or  by  the  nail  of  the  index-finger  of  one  hand,  while  with  the 
other  introduced  through  a  perineal  incision  (if  this  has  been  deemed  necessary) 
or  into  the  rectum  as  a  guide  and  for  counter-pressure,  the  organ  may  be  hulled 
out  without  danger  to  the  large  bowel. 

In  the  opinion  of  the  author,  perineal  prostatectomy  (as  advised  by  Dr.  Hugh 
H.  Young)  is  the  operation  of  choice  in  a  very  large  proportion  of  all  cases  of 
hypertrophy  of  the  entire  prostate.  The  patient  should  be  placed  in  the  lithotomy 
position,  a  sound  having  been  first  introduced  into  the  deej")  urethra.  An  incision 
in  the  median  line  is  made  from  near  the  scrotal  crease  to  within  half  an  inch 
of  the  anal  margin.  In  fat  subjects,  or  when  more  room  may  be  needed,  to  this 
may  be  added  a  transverse  curved  incision  half  an  inch  anterior  to  and  parallel 
with  the  circle  of  the  anus.     This  incision  shoitld  expose  the  bulb  of  the  urethra, 


THE   PROSTATE 


551 


the  central  tendon,  and  the  edges  of  the  levator  ani  muscle  (Fig.  560a).  The 
central  tendon  is  then  divided  close  to  the  margin  of  the  levator  ani  and  turned 
down.  By  keeping  close  to  the  capsule  of  the  prostate  in  the  dissection,  wounding 
the   rectum   should  be   avoided.      However,   under   certain  exceptional   conditions, 


Fig.  S60a. — Showing  the  bulb  of  the  u 
of  the  levator  ani.      Y 


■;il  tendon  below,  and  laterally  the  edg 
position.     (After  Young.) 


when  the  enlargement  is  excessive  and  when  adhesions  due  to  preexisting  inflam- 
mation are  firm  and  extensive,  this  accident  mnj  be  unavoidable.  When  it  occurs, 
the  opening  should  be  temporarily  closed  with  the  forceps  to  prevent  infection, 
and  as  soon  as  the  enucleation  has  been  completed  it  should  he  repaired  by  suture. 


\ 

X 

%N 

, 

""'Wx 

v^^ 

X 

:/''^ 

^ 

1-               ^ 

X  ^ 

s\^ 

4^     **i 

-/ 

NN. 

y/ 

/       ^^ 

*^ 

\ 

^ 

^JK  ^ 

/' 

K 

|^^!^|H 

n 

1"  '\^ 

/  i 

m^ 

'^i^ 

i 

r''  \ 

^■^ 

-^^ 

^ 

,^^'' 

"N^'*  *<^^ 

Fig.  5606. — Showing  the  incision  into  the  urethra  and  the  thread-loops  inserted,      (.^fter  Young.) 


552 


THE .  PROSTATE 


With  the  souBcl  which  has  already  l^een  introduced  as  a  guide,  a  small  longi- 
tudinal incision  is  made  into  the  urethra  through  the  membranous  portion,  and 
two  linen  threads  inserted,  as  sho^vn  in  Fig.  560&.  The  sound  is  now  withdrawn, 
and  through  this  opening  Young's  tractor  is  inserted  into  the  bladder,  the  blades 
turned,  and  the  lateral  and  posterior  retractors  placed  into  position.  The  pros- 
tatic tractor  draws  the  gland  outward  while  the  rectum  is  displaced  backward, 
which,  with  strong  lateral  retraction,  fully  exposes  the  entire  anterior  and  inferior 
surfaces  of  the  prostate.  An  incision  about  1.5  cm.  deep  is  now  made  on  each 
side  of  the  median  line  for  almost  the  entire  length  of  the  anterior  surface  of  the 
prostate.  These  two  lines  diverge  from  before  backward,  being  separated  1.8  cm. 
posteriorly  and  1.5  cm.  anteriorly   (Fig.  560c).     The  bridge  of  tissues  which  lies 

between  these  two  incisions  contains 
the  ejaculatory  ducts,  the  preservation 
of  which  is  important  (Fig.  560d). 
Through  these  incisions  in  the  capsule 
each  lateral  lobe  is  hulled  out  with  the 
blunt  dissector  (Fig.  560e).  The  outer 
portion  of  each  lateral  half  should  be 
first  separated  from  the  capsule,  and 
great  care  is  necessary  in  separating 
the  inner  half  to  prevent  tearing  into 
the  urethra,  an  accident  which  may 
occur,  however,  when  the  adhesions  are 
strong.  Enucleation  of  the  inner  por- 
tion is  facilitated  by  seizing  the  tumor 
with  forceps  and  making  outward 
traction,  as  shown  in  Fig.  560/.  At 
this  stage  of  the  operation  the  blunt 
dissector  should  be  discarded,  and  the 
index-finger  used.  After  the  lateral 
lobes  have  been  enucleated,  a  careful 


Fig.  .560c. — Showing  Young's  tractor  introduced 
and  the  lateral  incisions  into  the  substance 
of  the  prostate  on  either  side  of  the  urethral 
canal.      (After  Young.) 


Fig.  oQOd. — Cross-section  of  the  prostate  and  ure- 
thra, showing  the  strip  of  prostate  which  con- 
tains the  ejaculatory  ducts  and  which  is  not 
removed.     (After  Young.) 


examination  should  be  made  and  any  median  enlargement  also  removed  through 
one  of  the  lateral  incisions. 

Having  removed  the  tractor  and  thoroughly  irrigated  the  bladder  and  wound, 
the  operator  should  carefully  search  for  any  injury  to  the  bowel.  The  edges 
of  tlie  levator  ani  muscle  should  be  approximated  with  a  strong  suture  of 
chromicized  catgut,  No.  2,  and  the  central  tendon  stitched  back  to  its  original 
attachment. 

It  is  very  important  to  see  that  the  bladder  is  emptied  of  blood  before  the 
patient  leaves  the  operating  table,  and  that  the  drainage  apparatus  is  thoroughly 
in  place  and  kept  in  order  after  the  patient  is  put  to  bed.  This  consists  of  a 
double  current,  soft-rubber  tube,  or  two  tubes  which  pass  into  the  bladder  through 
the  incision  in  the  membranous  urethra.  A  light  gauze  pack  is  inserted  laterally." 
Young  advises  in  all  cases  a  submammary  infusion  of  one  thousand  cubic  centi- 


THE   PROSTATE 


553 


metres  of  salt  solution,  to  be  given  while  the  patient  is  on  the  operating  table. 
"  This  is  considered  so  Taluable,  both  as  a  preventive  to  shock  and  anuria  and  as  a 


Fig.  560e. — Enucleation  of  the  outer  portion  of  each  lateral  lobe  with  the  blunt  dissector. 
(After  Young.) 

cure  for  post-operative  thirst,  that  it  is  never  omitted."     The  gauze  drain  is  re- 
moved one  day  after  the  operation,  and  no  more  packing  employed.     The  tube 


Fig.  560/. — Traction  with  the  prostatic  forceps.     (After  Young.) 

is  pulled  out  a  few  hours  later,  and  the  next  day  the  patient  is  usually  placed  in 
a  wheel  chair  and  carried  out-doors.     Xo  sounds  are  passed  and  stricture  never 


554 


THE   PROSTATE 


results.    TJrotropin  is  given  earl)',  and  water  in  abundance.     (Young.)     The  normal 
relation  of  the  prostate  is  shown  in  Fig.  560,  while  the  changes  which  are  present 


in  hypertrophy  are  given  in  Fig.   563. 


The  relation  of  the  ejaculatory  duct  is 
shown  in  Fig.  557.  The  impediment  to 
the  complete  evacuation  of  the  bladder 
in  enlargement  of  the  posterior  and  mid- 
dle portions  of  this  body  is  shown  in 
Fig.  558. 

A  reference  to  Fig.  562  will  show  the 
changes  which  occur  in  the  general  con- 
tour of  the  jDosterior  urethra  in  connec- 
tion with  prostatic  hypertrophy,  more  es- 
pecially that  form  wliich  projects  back- 
ward into  the  bladder.  Fig.  560  shows 
the  normal  curve,  and  the  shariD  forward 
curve  of  the  deep  urethra  is  shown  in 
Fig.  563  as  a  result  of  the  enlargement. 

In  hopeless  cases  of  cystitis  resulting 
from  obstruction  of  the  urethra  from 
prostatic  hypertrophy,  malignant  neo- 
plasms, or  any  cause,  in  rare  instances 
the  establishment  of  a  permanent  urin- 
ary fistula  may  become  necessary.  After 
a  suprapuljic  operation  has  been  performed  and  the  wound  has  contracted  upon 
the  ordinary  drainage-tube,  this  may  be  removed  and  a  permanent  apparatus  such 
as  shown  in  Fisf.  565  inserted. 


Fig.  561. — The  sound  passing  around  the  normal 
curve  of  the  urethra.  (After  Van  Bureu  and 
Keyes.) 


Fig.  5C2. — The  change  in  the  direction  of  tlie  urethra  caused  bj'  lij-pertrophy  of  the  prostate. 
(After  Socin.) 


THE   PROSTATE 


555 


This  consists  of  a  large-sized  soft  Xelaton  catheter,  Trhich  is  carried  through 
the  fistulous  opening  until  it  rests  comfortably  within  the  bladder,  usually  aljout 
three  inches  from  the  level  of  the  integument.  This  catheter  is  made  to  pass 
through  a  perforated  hard-rubber  plate  about  three  inches  long  and  two  inches 
wide.  To  the  corners  of  this  plate  are  fastened  four  tapes,  two  of  which  are 
carried  around  the  body  and  tied,  the  other  two  passing  under  the  perineum,  in 
the  same  way  as  the  perineal  straps  of  a  truss,  to  hold  the  drainage  catheter  firmly 
in  its  proper  position.  When  the  wound  is  entirely  healed,  and  the  patient  begins 
to  move  about,  a  rubber  urinal,  vchich  receives  the  outer  end  of  the  catheter,  is 


Fig.  563. — Showing  the  increase  in  the  curve  of  the  ure- 
thra in  prostatic  hypertrophy,  and  the  necessity'  of  a 
longer  curve  In  the  catheter.  (After  Van  Buren  and 
Keyes.) 


Fig.  564. — A  ridge  of  hj'pertrophied  pros- 
tate seen  from  within  the  bladder.  (Af- 
ter Socin.) 


fastened  to  the  inner  side  of  the  thigh  and  leg.  This  urinal  extends  down  the  leg, 
and  is  so  arranged  that  by  turning  a  little  stopcock  situated  near  the  ankle  it  may 
be  emptied  when  necessary. 

Prostatorrhwa. — Chronic  prostatitis,  or  catarrh  of  the  prostate,  in  a  majority 
of  cases  follows  an  acute  inflammation  of  this  organ  (gonorrhcea).  Its  chief 
cause  is,  therefore,  an  extension  of  a  cj'stitis  or  urethritis  to  the  epithelial  lining 
of  the  glandular  portions  of  this  body.  In  a  certain  proportion  of  cases  it  origi- 
nates as  a  subacute  inflammatory  process,  located  in  the  glandular  substance.     It 


Fig.  565. — Dr.  F.  Tilden  Brown's  permanent  suprapubic  apparatus  for  bladder  d: 


is  in  this  form  most  frequently  seen  in  weak,  scrofulous,  or  tubercular  adults  abotit 
the  period  of  puberty.  Prosta"torrho?a  is  a  symptom  of  general  h}-pertrophy  of  this 
organ  in  the  earlier  "stages  of  enlargement,  gradually  diminishing  as  the  connective- 
tissue  In^Derplasia  encroaches  upon  and  destroys  by  compression  the  glandular 
apparatus. 


556  THE   PROSTATE 

The  leading  symiDtom  of  this  disease  is  the  discharge  of  a  small  quantity  of 
bluish-wliite  fluid  from  the  meatus.  It  is  noticed  particularly  by  the  ^Datient  before 
the  first  micturition  in  the  morning,  having  accumulated  during  the  night.  A 
drop  or  two  may  be  squeezed  from  the  urethra  by  pressure  along  the  under  sur- 
face of  the  penis  from  the  perinaum  forward.  It  is  carried  out  with  the  first 
flow  of  urine,  and,  if  not  observed  previously,  usiially  escapes  notice.  In  the 
severer  type  of  cases  the  prostatic  fluid  may  be  seen  immediately  after  urinating 
or  during  the  intervals  of  micturition,  as  a  Ifluish  mucus,  moistening  the  meatus 
and  prepuce,  and  slightly  tenacious  and  stringy  when  wiped  off.  This  fluid  is 
also  frequently  observed  when  the  contents  of  the  rectum  are  discharged,  especially 
if  the  fffices  are  hard  and  fully  formed.  Prostatorrhoea  occurs  in  excessive  or 
prolonged  venereal  excitement. 

The  diagnosis  depends  upon  the  exclusion  of  spermatorrhcea  and  urethritis. 
The  symptoms  of  spermatorrhoea  are  in  general  so  similar  to  those  of  prostatorrhcea 
that  a  positive  differentiation  can  only  be  made  by  microscopical  examination.  The 
fluid  which  escapes  may  be  examined  alone,  or  the  first  ounce  or  two  of  urine 
passed  after  a  comparatively  long  interval  in  urinating  may  be  caught  in  a  sepa- 
rate vessel,  allowed  to  settle,  and  a  drop  of  the  sediment  placed  upon  the  slide. 
The  j)resence  of  spermatozoa  will  confirm  the  diagnosis  of  spermatorrhoea.  The 
urine  first  passed  after  a  discharge  of  semen  should  not  be  examined,  since  under 
such  conditions  these  elements  are  found  in  perfectly  normal  subjects.  In  difEer- 
entiating  between  prostatorrhcea  and  gleet,  the  exploration  of  the  urethra  will  be 
necessary.  The  absence  of  a  stricture  or  of  marked  tenderness  in  the  canal  in  front 
of  the  prostatic  portion  will  exclude  urethritis,  with  the  exception  of  a  rare  form 
of  chronic  follicular  urethritis,  which,  as  will  be  seen  farther  on,  may  or  may  not 
be  preceded  by  a  gonorrhoea  or  stricture.  In  follicular  urethritis,  tenderness  is 
not  marked.  If  a  large-sized  bulbous  wire  bougie  is  carried  back  to  the  mem- 
branous portion  of  the  urethra,  and  is  then  withdrawn  while  the  urethra  is  held 
in  close  contact  with  it,  the  yellowish-white  flakes  or  plugs  of  cheesy  material 
will  be  squeezed  out  of  the  follicles  and  be  seen  adhering  to  the  bulbs. 

Treatment. — The  correction  of  any  diathesis  which  predisposes  to  a  catarrhal 
condition  of  the  mucous  membranes  is  an  important  step  in  the  general  treatment 
of  iDrostatorrhcea. 

Among  the  local  measures,  distention  of  the  iDrostatic  urethra  by  the  introduc- 
tion of  steel  sounds  is  advisable.  The  larger  sizes  should  be  employed,  and  if  the 
meatus  is  so  narrow  that  it  will  not  admit  No.  20  or  21  (U.  S.),  it  should  be 
incised  up  to  this  point  as  a  preparatory  measure.  When  stricture  exists,  internal 
urethrotomy  should  be  performed.  The  dilatation  may  be  commenced  with  No. 
17  and  increased  to  No.  21  at  a  single  operation;  or,  if  the  procedure  is  attended 
with  pain  of  a  severe  nature,  the  larger  numbers  may  he  used  at  the  third  or 
fourth  introduction.  The  point  of  the  sound  should  not  be  carried  farther  than 
the  neck  of  the  bladder,  which  is  between  seven  and  eight  inches  from  the  meatus. 
The  operation  should  be  repeated  from  two  to  three  times  a  week — not  often  enough 
to  cause  a  general  urethritis. 

Ijocal  medication  is  at  times  of  great  value.  The  method  which  yields  the 
best  results  is  the  deep  injection  of  nitrate  of  silver,  varying  in  strength  from 


Fig.  566. — Keyes-Ultzman  syringe. 

ten  to  forty  grains  to  the  ounce.  As  a  rule,  a  ten-grain  solution  is  the  proper 
strength  to  commence  with,  and  is  increased  as  the  exigencies  of  the  case  demand. 
The  instrument  employed  is  the  Keyes-Ultzman  syringe  (Fig.  566).  Under  the 
ordinary  aseptic  rules  the  syringe  is  filled  with  the  proper  -solution,  lubricated  with 


THE   PROSTATE    ,  557 

glj'cerine,  and  carried  back  until  the  point  can  be  felt  to  pass  behind  the  cut-ofj 
muscle  and  rests  in  the  deep  or  prostatic  urethra.  The  quantitj^  of  the  solution 
injected  is  usuallj'  from  five  to  ten  minims,  repeated  every  two  or  three  days. 
It  is  usually  followed  by  a  slight  and  temporary  sense  of  irritation  or  burning. 

Spermatorrliwa. — This  term  is  used  to  designate  the  escape  of  semen  from  the 
ejaculatory  ducts  without  an  orgasm.  This  fluid  may  find  its  way  into  the  blad- 
der, but  usually  escapes  by  the  meatus.  The  symptoms  of  this  .disease  do  not 
differ  materially  from  those  given  in  pirostatorrhoea.  The  diagnosis  can  only 
be  made  certain  by  the  recognition  of  the  spermatozoa  with  the  aid  of  the  micro- 
scope. It  occurs  at  times  in  conditions  of  great  physical  prostration,  as  a  result 
of  excessive  and  unnatural  venereal  indvdgence,  and  from  interference  with  the 
function  of  the  muscular  elements  of  the  prostate. 

The  treatment  is  general  and  local.  Measures  looking  to  the  improvement  of 
the  moral  and  physical  condition  of  the  patient  should  be  adopted.  The  local 
treatment  is  the  same  as  that  given  for  prostatorrhoea. 

Aspermatism. — The  spermatozoa  are  wanting  in  adults  whose  testicles  have 
been  removed  or  destroyed  by  disease,  in  patients  in  whom  both  organs  have  failed 
to  descend  and  have  undergone  atrophy;  in  all  cases  of  complete  obstruction  of 
the  vasa  deferentia  or  ejaculatory  ducts,  and  in  certain  cases  of  senile  atrophy  of 
these  organs.     These  conditions  are  rarely  amenal^le  to  surgical  treatment. 

Tuberculosis  of  the  Prostate. — Tiiliercular  disease  of  this  organ,  though  rarely 
observed,  maj^  be  primary,  or  more  frequently  is  secondary,  to  tubercular  deposit 
in  other  viscera,  as  the  testis,  epididymis,  lungs,  etc.  It  is  more  apt  to  occur  in 
the  young  and  middle-aged  than  in  the  old.  The  diagnosis  cannot,  as  a  rule,  be 
easily  made.  In  some  cases  there  are  no  symptoms  of  tuberculosis.  If  with  a 
subacute  or  chronic  lesion  of  this  organ  there  is  a  history  of  phthisis,  the  deposit 
of  tuljercular  matter  may  be  suspected.  Wlien  the  febrile  movement,  hectic  flush, 
profuse  sweats,  and  emaciation  of  this  disease  are  present,  a  correct  diagnosis  is 
readily  made.  The  enlargement  and  nodular  character  of  the  prostate  may  be 
made  out  by  digital  exploration  by  the  rectum.  The  treatment  is  palliative  if 
general  tuberculosis  exists,  or  operative  if  the  disease  is  local. 

C arcinoma. — Cancer  of  the  prostate  is  also  rare.  It  is  more  apt  to  occur  pri- 
marily than  by  metastasis.  Primarj'  cancer  of  this  organ  is  more  frequently  seen 
in  young  adults  than  in  the  old.  In  the  middle-aged  and  old  it  is  more  likely 
to  occur  Ijy  invasion  from  a  neighboring  organ,  as  the  rectum. 

In  the  earlier  stages  the  sraiptoms  of  this  disease  do  not  differ  materially 
from  those  of  simple  hypertroplw.  As  simple  hypertrophy  is  rare  in  the  young 
and  middle-aged,  the  presence  of  a  tumor  of  this  organ  at  this  time  of  life  should 
be  regarded  with  a  suspicion  of  malignancy.  The  absence  of  the  symptoms  of 
abscess  is  in  some  degree  a  confirmation  of  this  suspicion.  If  the  tumor  develops . 
rapidly,  carcinoma  or  sarcoma  may  be  diagnosticated,  for,  although  the  disease 
may  continue  for  one  or  two  years,  or  even  longer,  the  invaded  organ  soon  assumes 
a  size  not  met  with  in  non-malignant  hypertrophy.  Haemorrhage  of  a  profuse 
character  is  apt  to  follow  the  introduction  of  a  sound  or  catheter  when  carcinoma 
or  sarcoma  is  present. 

Sarcoma  is  also  rare  in  this  organ  (Fig.  567).  It  is  more  apt  to  occur  in  the 
young  than  in  the  middle-aged  and  old.  The  symptoms  differ  in  no  essential 
feature  from  those  present  in  cancer.  The  prognosis  of  both  diseases  is  grave, 
and  the  treatment  palliative. 

Prostatic  Concretions. — Concretions  in  this  organ  are  of  two  kinds — the  cor- 
pora amylacea  and  calculi.  The  former  are  small  bodies  which  frequently  exist 
in  the  follicles  of  the  prostate.  Their  mode  of  origin  is  unknown.  They  give  the 
well-known  am^doid  reaction  with  iodine.  Stone  in  the  prostate  may  originate 
in  the  deposit  of  inorganic  elements  from  the  blood  and  fluids  of  this  organ,  either 
in  the  follicles  originally  (Fig.  568)  or  as  accretions  upon  the  amyloid  bodies 
just  described. 

The  symptoms  of  prostatic  concretions  are  chiefly  those  due  to  the  inflammation 
or  enlargement  which  they  produce.  Corpora  amylacea  not  infrequently  exist  in 
the  prostate,  causing  little  or  no  discomfort.     When  of  large  size,  especially  when 


558 


THE   PROSTATE 


thev  o-row  by  reason  of  a  deposit  of  inorganic  substances,  they  cause  inflammation 
of  "tlie  follicles  and  destruction  of  the  glandular  epithelia.  A  positive  diagnosis 
can  only  be  made  by  bringing  a  sound  or  catheter  in  contact  with  the  concretion. 
When  tiie  stone  is  situated  in  the  deeper  portions  of  the  organ  it  will  escape  detec- 
tion by  this  method,  but  the  tumefac- 
tion it  causes  may  be  recognized  by 
digital  exploration  per  rectum. 


Fig.  567. — Sarcoma  of  the  prostate  and  neck  of 
the  bladder,  with  obstruction.  The  catlieter 
has  tunneled  the  neoplasm.     (After  Socin.) 


Fig.  5CS. — Calculi  in  the  prostatic  follicles. 
(After  Socin.) 


The  interference  with  the  escape  of  urine  caused  by  calculi  of  the  prostate 
is  analogous  to  that  which  occurs  with  general  hypertrophy  of  the  body  of  this 
organ.  The  stream  of  urine  is  diminished,  but  remains  about  the  same  size,  and 
escapes  steadily  throughout  the  act  of  urination.  There  is  no  sudden  and  com- 
plete interruption  of  the  current,  as  in  stone  in  the  bladder,  or  in  enlargement 
of  the  middle  lobe  of  the  prostate.  Calculi  of  this  organ  may  escape  into  the 
urethra  and  lodge  there,  or  work  their  way  back  into  the  bladder,  or  pass  out  at 
the  meatus. 

The  treatment  is  palliative  until  operative  interference  is  necessitated  on  ac- 
count of  pain  or  dysuria.  Either  lobe  may  be  incised  and  the  concretions  removed 
liy  following  the  technic  given  for  perineal  prostatectomy.  Should  hypertrophy 
be  present,  removal  of  the  prostate  may  be  advisable. 

Neuralgia  of  the  prostate  and  neck  of  the  bladder  is  occasionally  observed; 
Pain  is  present  in  this  organ  when  no  symptoms  of  inflammation  are  discoverable. 
It  is  usually  exaggerated  during  and  immediately  after  micturition,  and  after  a 
seminal  emission.  The  introduction  of  a  sound  shows  great  tenderness  of  the 
deep  urethra.  The  instrument  carried  into  the  bladder  does  not  produce  the  tenes- 
mus and  pain  common  to  cystitis.  An  examination  of  the  urine  will  demonstrate 
the  absence  of  pus,  which  will  also  serve  to  exclude  inflammation  of  the  bladder  or 
prostate.  The  causes  of  this  infection  are  as  a  rule  obscure.  Irregular  or  exces- 
sive venereal  indulgence  is  considered  to  be  one  of  the  most  frequent  causes  of 
neuralgia  in  this  organ.  The  treatment  involves  the  removal  of  every  possible 
source  of  irritation.  The  constitutional  measures  recommended  in  neuralgia  in 
other  jiarts  of  the  body  should  be  employed.  Locally  the  galvanic  current  is 
especially  indicated.  If  the  urine  is  extremely  acid  and  burning,  benefit  will 
be  derived  from  the  administration  of  large  quantities  of  alkaline  and  diluent 
drinks. 

Seminal  Vesicles. — The  seminal  vesicles  are  occasionally  absent  from  failure 
of  development,  or  they  may  be  obliterated  as  a  result  of  cicatricial  contraction 
after  infection,  while  they  are  occasionally  destroyed  by  operation. 

Inflammation  of  the  seminal  vesicles  is  caused  by  the  extension  of  an  infection 
from  the  urethra,  prostate,  bladder,  rectum,  and  vas  deferens.  In  occlusion  of 
the  ejaculatory  duct  there  is  always  an  overdistention  of  these  organs.  Several 
cases  of  calculus  in  the  ducts  have  been  recorded.  Gonorrhcea  is,  in  all  probability, 
the  most  frequent  cause  of  serious  seminal  vesiculitis. 


THE   PROSTATE  559 

The  specific  organisms  of  this  disease  long  after  the  first  acute  symptoms  have 
subsided  lie  concealed  in  the  deeper  follicles  of  the  prostate  and  probably  in  the 
seminal  vesicles,  to  declare  themselves  by  renewed  outbreaks  of  infection  under 
conditions  favorable  for  their  proliferation  and  dissemination. 

In  all  probability  the  so-called  prostatic  neuralgia  is  due  in  large  measure  to 
chronic  subacute  inflammation  of  the  seminal  vesicles  following  gonorrhrea.  These 
vesicles  are  also  at  times  the  seat  of  localized  tuberculosis,  and  their  function  must 
always  of  necessity  be  more  or  less  impaired  by  any  hypertrophy  of  the  prostate. 

In  the  treatment  of  chronic  vesiculitis  with  hyperdistention,  intrarectal  mas- 
sage has  been  recommended.  This  can  l3e  done  digitally  or  by  the  use  of  a  large 
glass  rod  with  proper  curve  and  with  a  knoblike  end.  This  is  introduced  into  the 
rectum  and  kneading  done  from  above  do^^^lward.  In  a  certain  proportion  of 
eases  of  chronic  vesiculitis,  where  pain  is  persistent,  operative  intervention  may 
be  demanded.  Prof.  Eugene  Fuller  has  devised  the  following  operation,  which  he 
has  practiced  in  a  number  of  instances  with  satisfactory  results : 

The  patient,  properly  pirepared  and  anesthetized,  is  placed  upon  the  operating 
table  in  the  prone  position  with  the  thighs  abducted  and  flexed  upon  the  alxlomen. 

The  incision  on  the  right  begins  a  little  above  the  upper  border  of  the  patient's 
coccyx,  just  inside  the  right  ischium,  then  extends  slightly  downward,  keeping 
just  within  the  border  of  that  bone  and  ending  about  three  fourths  of  an  inch 
anteriorly  to  the  anterior  margin  of  the  anus.  A  similar  incision  is  made  on 
the  opposite  side,  and  these  are  joined  in  front  of  the  anus  by  a  transverse  cut. 
The  longitudinal  cut  should  be  deep  enough  to  divide  all  the  fatty  tissues  of  the 
ischio-rectal  space,  and  dividing  above  a  few  of  the  lower  fibers  of  the  gluteus 
maximus  muscle.  The  transverse  cut  is  then  deepened,  the  anterior  layer  of  the 
deep  fascia  being  cut  through.  Great  care  should  be  taken  in  cutting  down  trans- 
versely to  avoid  wounding  the  sphincter  ani  muscle.  The  curved  forefinger  of 
the  operator's  left  hand  should  be  inserted  into  the  rectum,  the  ball  of  the  tip 
l)cing  turned  downward  against  tlie  anterior  rectal  wall,  while  the  corresponding 
thumb  presses  against  the  loosely  dissected  rectum,  the  hand  at  the  same  time 
exercising  upward  traction.  The  bowel  is  thus  held  up  in  the  grasp  of  the  thumb 
and  the  forefinger,  while  the  operator  dissects  more  deeply,  cutting  through  the 
levator  ani  muscle  and  the  visceral  layer  of  the  pelvic  fascia.  As  the  narrow 
pathway  of  this  dissection  is  between  the  urethra  and  the  rectvim,  the  knife  or 
dull-pointed  scissors  should  be  kept  well  against  the  anterior  rectal  wall.  When 
the  fibers  of  the  levator  ani  muscle  are  divided,  the  iipper  flap,  which  includes 
the  rectum,  spontaneously  retracts  or  may  be  raised  well  out  of  the  way.  As  the 
dissection  ioecomes  deeper,  the  operator's  right  forefinger  may  be  used  to  sepa- 
rate the  tissues  instead  of  an  instrument,  and  the  path  of  the  wound  over  the 
prostate  divulsed  by  separating  the  fingers.  In  the  deeper  dissection  it  is  com- 
])aratively  easy  to  strip  the  loose  rectal  connections  from  the  seminal  vesicles  and 
the  posterior  bladder  wall.  The  vesicles  are  now  opened  by  means  of  a  free  longi- 
tudinal incision,  and  their  cavities  thoroughly  curetted.  A  light  wicker  drain 
is  inserted  in  the  trough  of  the  opened  vesicles.  -  This  may  be  removed  within 
five  days  or  a  week.  The  operation  being  completed,  the  walls  of  the  wound  should 
he  carefully  adjusted  by  deeper  sutures  so  as  to  bring  the  rectum  back  into  its 
original  position.  A  space  for  gauze  packing  should  be  left  in  the  middle  portion 
of  "the  transverse  cut.  Temporary  retention  of  the  urine  requiring  the  catheter 
is  apt  to  follow,  especially  where  extensive  gauze  packing  has  been  found  necessary.^ 

1  Eugene  Fuller,  "Jour.  A.  M.  A.,"  May  4,  1901;   "N.  Y.  Med.  Rec,"  May  21,  1904. 


CHAPTER    XXX 

THE       UEETHKA PENIS TESTICLES SCEOTFM BALANITIS POSTHITIS PHIMOSIS 

OKCHITIS BUBO — iGONOEKHCEAL      EHEUjMATISM CHEONIC      UEETHEITIS 

STEICTUEE URETHROTOMY DILATATION DIVULSION FOREIGN     BODIES URE- 

THEO-EECTAL  FISTULA HYPOSPADIAS EPISPADIAS NEOPLASMS HUMPHREY'S 

OPERATION CIRCUMCISION ULCER HEMATOMA FISTUL.F ELEPHANTIASIS 

^HYDEOCELE VARICOCELE EPIDIDYMITIS NEOPLASMS     OF     TILE     TESTICLE — 

MALPOSITION 

GONOREHCEA  will  1)6  Considered  in  the  chapter  on  infectious  diseases. 

Among  the  complications  of  gonorrhcea  are  balanitis,  posthitis,  paraphimosis, 
prostatitis,  cystitis,  epididymitis,  orchitis,  bubo,  ophthalmia,  arthritis,  and  reten- 
tion of  urine. 

Balanitis  and  posthitis,  inflammation  of  the  glans  and  prepuce,  are  conditions 
existing  in  a  varying  degree  in  almost  all  cases  of  gonorrhoea.  Among  the  cir- 
cumcised, or  those  with  short  and  retracted  foreskins,  posthitis  need  not  occur, 
Init  the  acrid  discharge  will  always  affect  the  epithelial  covering  of  the  glans  in 
the  immediate  neighborhood  of  the  meatus.  When  the  foreskin  is  long  and  ad- 
herent, or  not  readily  drawn  behind  the  glans,  it  usually  becomes  swollen  and 
tense,  retains  the  irritating  discharge,  and  inaugurates  an  exceedingly  painful 
and  annoying  condition  of  phimosis.  Even  when  thus  swollen,  if  the  prepuce 
can  be  retracted,  it  is  apt  to  be  caught  behind  the  corona  and  become  irreducilDle, 
with  ensuing  strangulation,  if  not  relieved  b}^  operative  interference.  Preputial 
sloughing  will  occur  in  a  certain  proportion  of  neglected  eases. 

In  the  treatment  of  gonorrhoea  certain  measures  were  detailed  looking  to  the 
prevention  of  these  complications.  When,  however,  they  are  present  in  a  mild 
degree,  balanitis  and  posthitis  disappear  with  proper  attention  to  cleanliness.  The 
glans  and  prepuce  should  be  irrigated  by  being  submerged  in  a  vessel  of  warm 
water.  Soap  should  not  be  employed.  The  hip-bath,  already  given  as  useful  in 
the  general  management  of  the  disease,  is  especially  so  in  this  compilication. 

The  inflammatory  phimosis  of  gonorrhoea,  as  of  non-specific  balano-posthitis, 
demands  active  measures  of  treatment.  In  milder  cases  it  may  suffice  to  main- 
tain cleanliness  by  the  frequent  subpreputial  injection  of  tepid  water.  For  this 
purpose  a  syringe  with  a  delicate  dull  ]5oint  or  nozzle,  about  an  inch  in  length, 
is  needed.  It  should  be  oiled,  carefully  introduced  between  the  glans  and  pre- 
puce, and  the  contents  slowly  discharged.  An  irrigating  apparatus  may  also  be 
attached  to  the  nozzle,  and  a  continuous  current  applied,  which  does  away  with 
the  irritation  of  repeated  introductions  of  the  nozzle.  If  these  milder  measures 
do  not  relieve  the  pain,  tension,  and  threatened  strangulation,  an  incision  should 
be  made.  The  pre])uce  may  be  nicked  in  several  places,  or  a  director  introduced 
in  the  median  line  above,  along  the  groove  of  which  a  bistoury  is  carried,  and 
the  division  effected. 

When  inflammatory  paraphimosis  exists,  adhesions  rapidly  occur  at  a  point 
just  behind  the  corona,  on  the  dorsum  penis,  rendering  a  reduction  impossible 
unless  these  transverse  bands  are  divided.  The  reduction  of  a  paraphimosis  is 
undertaken  in  this  manner.  The  organ  is  held  in  a  vessel  of  cold  water  for  a  few 
minutes,  or  cold  cloths  are  wrapped  loosely  over  and  around  the  swollen  parts. 
When  removed,  the  glans  and  prepuce'  are  thoroughly  lubricated,  and  the  organ 
grasped  so  that  while  the  soft  parts  of  the  thumbs"  press  the  glans  backward,  the 

560 


THE   URETHRA  561 

fingers  are  drawing  the  prepuce  to  the  front.  Or  the  penis  may  be  grasped  by 
the  thumb  and  finger  of  the  left  hand,  and  the  foreskin  di-awn  forward  while  the 
glans  is  pushed  backward  by  the  thumb  and  fingers  of  the  opposite  member. 
When  the  reduction  is  accomplished,  the  patient  should  be  directed  to  make  every 
effort  to  prevent  a  recurrence  of  the  accident. 

If  the  efforts  at  reduction  fail,  the  contractions  on  the  dorsum,  behind  the 
glans.  should  be  divided  by  one  or  more  incisions  in  the  long  axis  of  the  penis. 
(Edema  of  the  prepuce,  especially  of  the  lower  portion,  is  apt  to  occur,  even  ia 
cases  of  recent  paraphimosis,  and,  when  the  condition  has  existed  for  a  day  or  two, 
infiltrations  occur,  which  may  persist  for  a  long  time  after  the  constriction  is 
relieved. 

Prostatitis  and  cystitis,  occurring  with  gonorrhoea,  require  treatment  not  dif- 
fering from  that  already  given.  Retention  must  be  relieved  by  the  small  soft 
catheter  or  bj'  suprapubic  aspiration.  Epididymitis,  or  inflammation  of  the  vas 
deferens  and  the  globus  major  and  minor,  is  one  of  the  most  painitd  complica- 
tions of  gonorrhcea.  Perfect  physical  quiet,  with  support  of  the  scrotum  and 
testicle,  are  essential.  At  the  earliest  indication  of  an  extension  of  the  infection 
along  the  vas  deferens,  every  effort  should  be  made  to  arrest  the  disease  before 
it  reaches  the  epididymis  or  to  confine  it  at  least  to  the  globus  major.  The  ana- 
tomical arrangement  of  the  globus  minor,  which  is  composed  of  a  single  tube  in 
numerous  convolutions,  makes  it  more  easy  of  occlusion  by  inflammation  than  the 
multiple  tubules  which  compose  the  globus  major.  Sterility  not  infrequently  fol- 
lows an  epididymitis  which  seriously  involves  the  globus  minor.  The  last  of  these 
measures  may  be  secured  by  using  the  handkerchief  sling,  which,  is  made  as 
follows : 

Attach  a  belt  or  piece  of  roller  around  the  waist,  above  the  pelvis;  fold  a 
good-sized  silk  handkerchief  in  a  triangular  shape,  carry  the  center  of  the  long 


Fig.  569. — Handkerchief  suspensorj-.      (After  Hill.) 

side  of  this  triangle  beneath  the  scrotum,  at  the  perineo-scrotal  junction,  attach 
one  of  the  long  ends  to  the  belt,  near  the  anterior  superior  spine  of  the  iliiuu, 
on  either  side,  and  bring  the  short  piece  directly  upward,  in  front  of  the  scrotum 
and  penis,  and  pin  it  to  the  belt  in  the  median  line;  or  the  ends  may  be  tied 
just  above  the  root  of  the  penis   (Fig.  569). 

Another  method  is  to  place  a  three-cornered  cushion  beneath  the  scrottim,  close 
up  to  the  perinaeum,  and  allow  the  testicles  to  rest  upon  this  support:  or  two 
thickly  folded  towels  may  be  pinned  together  and  carried  tightly  around  the  thighs 
at  the  level  of  the  perinreum. 

At  times  the  tension  of  the  parts  is  so  great  that,  not  only  to  relieve  pain,  but 
to  prevent  gangrene,  puncture  or  incision  is  imperative.  The  most  immediate 
relief  will  follow  this  operation.  A  sharp  narrow  blade  is  preferable,  and.  if  the 
instrument  is  not  made  for  this  especial  purpose,  it  may  be  extemporized  by  pro- 
jecting the  point  of  an  ordinary  sharp-pointed  bistoury  half  an  inch  beyond  the 
surface  of  a  cork  through  which  the  knife  is  thrust.  With  this  guard  attached, 
the  punctures  may  be  made  rapidly  and  without  danger  of  penetrating  too  deeply. 

Although  the  "procedure  is  very  painful,  it  is  usually  so  rapidly  accomplished 


562 


THE   URETHRA 


that  an  anesthetic  is  not  necessary.  The  injection  of  a  two-i3er-cent  cocaine  solu- 
tion will  afford  a  fair  degree  of  anesthesia.  The  operator  holds  the  scrotum  and 
testicle  so  as  to  make  tense  the  skin  over  the  epididymis  and  to  expose  it  properly 
to  view,  and  then  by  well-directed  and  rapid  thrusts  punctures  the  organ  in  from 
two  to  four  or  six  points,  scattered  over  the  induration.  A  free  discharge  of  dark 
or  black  blood  usually  follows,  and  in  from  twenty  to  thirty  minutes  the  pain  is 
greatly  if  not  entirely  relieved.  The  antiseptic  precautions  should  be  carried  out 
in  this  procedure. 

Orchitis  is  an  infrequent  affection  in  gonorrhcea.  The  treatment  is  in  general 
similar  to  that  of  the  last-named  disease.  The  diagnosis  is  readily  made  out  by 
the  touch,  for,  when  hydrocele  does  not  coexist,  the  induration  of  the  organ  cannot 
well  be  mistaken.  Poultices  of  tobacco  have  long  enjoyed  a  reputation  in  the 
treatment  of  orchitis  and  epididymitis,  but  when  warm  applications  are  indicated, 
well-saturated  and  frequently  changed  warm  cloths  will  be  found  equally  satis- 
factory in  the  effect  produced,  and  much  more  cleanly  than  the  poultices.  In  the 
majority  of  instances  cold  will  be  more  agreeable  than  heat.  The  ice-bag  may 
be  utilized  in  the  following  manner  with  great  satisfaction :  A  bladder  or  rubber 
bag  is  filled  with  crushed  ice,  placed  upon  the  three-cornered  perineal  cushion, 
and  the  inflamed  organ  allowed  to  rest  upon  it.  If  the  cold  is  too  great  for 
comfort  (and  the  patient  may  usually  be  relied  upon  to  determine  this),  a  layer 
or  two  of  lint  or  cotton  may  be  interposed.  It  occasionally  becomes  necessary  to 
puncture  or  incise  the  tunica  albuginea  in  orchitis  somewhat  after  the  fashion 
given  in  puncture  for  epididymitis.  Two  methods  are  employed,  namely:  to  carry 
a  sharp-pointed  long  knife  through  a  single  puncture  of  the  scrotum  down  to  the 
testicle,  and  incise  the  fibrous  capsule  in  one  or  more  places  parallel  with  its  long 
axis  and  along  its  anterior  surface;  or  to  use  an  instrument  similar  to  that  em- 
ployed in  epididymitis,  and  make  several  punctures  through  the  scrotum  and  the 
anterior  portion  of  the  capsule. 

Inguinal  adenitis,  or  biiio,  occurs  in  a  considerable  proportion  of  cases  of 
specific  urethritis,  and  is  apt  to  be  bilateral.  The  disease  is  readily  recognized  by 
the  swelling  in  the  groin.  The  inflammatory  process  is  usually  so  rapid  in  its 
invasion  that  the  different  glands  in  this  group  of  lymphatics  cannot  be  made  out, 
the  entire  group  being  matted  together  in  one  mass  of  embryonic  cells  infiltrating 
the  tissues  around  the  glands  as  well  as  involving  their  substance.  The  gonor- 
rhceal  bubo  tends  naturally  to  suppuration.  In  mild  cases,  and  where  the  proper 
measures  are  taken  at  the  early  appearance  of  the  adenitis,  this  disaster  may  be 
averted;  but  in  others,  partly  owing  to  the  unfavorable  condition  of  the  tissues 
and  to  the  continued  irritation  from  motion,  pus  formation  cannot  be  prevented. 

In  the  treatment  of  acute  inflammatory  bubo,  perfect  rest  is  imperative,  and 
the  dorsal  decubitus  should  be  maintained.  Local  medication  is  of  little  value. 
The  employment  of  cold  will  be  found  agreeable  in  the  earlier  stages  and  may 
serve  to  prevent  suppuration.  The  ice-bag  may  be  employed  by  laying  it  upon 
a  circular  pad  placed  around  the  bubo.  In  this  way  the  pressure  is  entirely  taken 
off  the  inflamed  surface.  After  the  formation  of  pus  is  inevitable,  warm  cloths 
or  poultices  should  be  substituted.  When  pus  is  formed,  a  free  incision  under 
cocaine  ansesthesia  should  be  made. 

Chronic  suppurative  acleniiis  of  the  inguinal  glands  occasionally  persists  long 
after  the  gonorrhoea  which  caused  it  has  disappeared.  The  only  remedy  is  to 
dissect  out  the  "diseased  glands  with  the  curved  scissors,  or  scrape  them  out  with 
Volkmann's  sjjoon. 

Gonorrhceal  proctitis  is  a  rare  aifection,  and  does  not  call  for  especial  con- 
sideration. 

Ophthalmia  resulting  from  the  inoculation  of  the  conjunctiva  with  the  virus 
of  specific  urethritis,  has  been  considered  with  lesions  of  the  eye. 

Gonorrhceal  Bheumatism. — In  a  certain  proportion  of  individuals  suffering 
from  gonorrhoea!  inoculation  at  a  period  varying  from  five  or  six  days  to  several 
weeks  from  the  date  of  the  attack,  symptoms  not  unlike  those  occurring  in  gout 
or  rheumatism  make  their  appearance  in  the  joints,  tendons,  and  burse,  and'less 
frequently  in  the  nerves  and  eye.     The  parts  involved  become  more  or  less  swollen 


THE   URETHRA  563 

and  painful.  The  pain,  however,  is  less  than  in  ordinary  rheumatism.  The 
febrile  movement  is  not  high,  and  the  character  of  the  urine  is  unchanged,  in 
both  of  which  features  it  differs  from  ordinary  rheumatism  (Fournier).  Neural- 
gia occasionally  supervenes  in  the  course -of  this  disease.  In  a  certain  proportion 
of  eases  the  eye  is  afEected,  but  the  ophthalmia  here  in  ro  way  resembles  that  of 
gonorrhoeal  conjunctivitis.  The  pathology  of  this  disease  is  not  understood.  It  is 
claimed  by  some  observers  that  the  diplococcus  occasionally  met  with  in  the  fluid 
removed  from  the  joints  in  this  affection  is  not  the  gonococcus  of  ISTeisser.  The 
treatment  is  entirely  expectant. 

Gonorrhcea  in  females  is  usually  less  severe  than  in  males,  and  yields  more 
readily  to  treatment.  The  chief  seat  of  the  inflammation  is  in  the  vagina.  The 
urethra  and  bladder  may  also  become  involved.  From  the  vagina  the  infection 
often  spreads  to  the  uterus  and  tubes,  resulting  in  sterility  by  occlusion  of  these 
ducts.  In  the  treatment,  quiet  is  of  first  importance.  The  warm  hip-hath  should 
be  employed  several  times  a  day,  and  the  vagina  irrigated  at  regular  intervals 
with  warm  permanganate-of-potash  solution  (1-5000),  thrown  in  from  a  fountain 
syringe. 

Non-specific  urethritis  may  be  caused  by  injury,  as  from  the  introduction  of 
a  catheter  or  any  foreign  body,  the  lodgment  of  a  calculus,  the  injection  of  an 
irritating  substance,  or  from  without,  as  in  striking  the  ijerinseinn  upon  the  saddle 
in  riding,  or  excessive  coitus.  It  may  also  result  from  infection  from  an  unclean 
vagina  or  urethra  in  which  pyogenic  yet  non-specific  bacteria  are  present.  It  is 
usually  of  short  duration,  mild  in  character,  and  does  not  involve  the  entire  length 
of  the  canal.  In  a  medico-legal  sense  it  may  be  necessary  to  determine  whether 
specific  infection  is  or  is  not  present,  and,  as  stated  on  a  previous  page,  this  can 
onl}'  be  decided  by  the  microscope,  together  with  a  careful  study  of  the  grosser 
symptoms  of  this  disease  already  given,  and  in  no  other  way.  Non-specific  ure- 
thritis should  be  treated  by  the  removal  of  the  offending  substance,  by  rest  and 
irrigation,  as  in  the  specific  form  of  the  disease,  and  sterilization  of  the  urine  is 
advisable. 

Gleet,  or  Chronic  Urethritis. — Gleet  is  a  name  given  to  the  prolonged  dis- 
charge- from  the  urethra  of  a  variable  quantity  of  muco-purulent,  bluish-white 
fluid.  This  discharge  is  a  transudation  from  the  mucous  and  glandular  epithelia 
of  the  urethra.  In  gleet,  all  or  an}'  limited  portion  of  this  tube  may  be  affected. 
The  pathological  change  is  a  puffiness  of  the  lining  membrane,  due  to  hyperemia 
of  the  subepithelial  vascular  area,  with  a  tendency  to  embryonic  and  connective- 
tissue  formation.  In  some  points  patches  of  erosions  or  tissue  necrosis  occur. 
The  epithelia  lining  the  glandular  apparatus — as  those  of  the  prostate,  Cowper's 
glands,  and  the  urethral  follicles — become  more  or  less  involved.  Not  infre- 
quently the  outlets  to  these  follicles  become  obstructed  bj''  the  superflcial  inflam- 
matory process,  resulting  in  the  formation  of  one  or  more  retention  cysts,  which 
project  into  the  lumen  of  the  tube. 

Any  form  of  acute  urethritis  may  pass  into  this  chronic  condition  of  gleet;  or 
a  urethritis  subacute  in  its  character  from  the  beginning,  may  continue  as  a  gleet. 

Although  chronic  urethritis  may  exist  without  the  presence  of  stricture  of  the 
urethra — as  in  follicular  urethritis — the  exceptions  to  this  rule  are  extremely  rare. 
Any  chronic  interference  with  the  normal  caliber  of  the  urethra  serves  to  induce 
a  catarrhal  condition  of  the  mucous  membrane  of  this  canal,  which,  commencing 
near  the  seat  of  stricture,  may  involve  any  portion  of  the  tuhe. 

The  treatment  of  gleet  involves,  primarily,  the  removal  of  the  cause.  Taking 
stricture  as  the  chief  cause,  urethrotomy  with  dilatation,  or  dilatation  without 
cutting,  is  demanded.  In  mild  cases  without  close  organic  stricture,  the  intro- 
duction of  the  steel  sound  will  often  effect  a  cure.  The  methods  of  procedure 
will  be  given  in  full  in  the  treatment  of  stricture  of  the  urethra. 

In  chronic  follicular  urethritis  it  is  best  to  examine  carefully  with  the  endo- 
scope (Fig.  570)  the  urethral  canal,  and  apply  nitrate  of  silver  directly  to  the 
diseased  surfaces. 

Stricture  of  the  Male  Urethra. — Strictures  of  the  urethra  may  be  divided  into 
two  classes:  true  or  organic,  and  false  or  spasmodic. 


,564  THE   URETHRA 

A  permanent  diminution  of  the  caliber  of  this  canal,  as  a  result  of  an  inflam- 
matory process,  constitutes  a  true  or  organic  stricture.  A  spasmodic  stricture 
exists  when  the  normal  caliber  is  diminished. as  a  result  of  contraction  of  the  vol- 
untary or  involuntary  muscular  elements  connected  with  the  urethra. 

Congenital  non-inflammatory  narrowing  of  the  meatus  does  not  constitute  a 
stricture.  The  normal  contraction  of  the  compressor-urethrfe  or  "  cut-off "  muscle 
is  also  excluded  in  the  definition  of  spasmodic  stricture. 


G.T-IEMANNSrCO;; 


Fig.  570. — Klotz's  endoscope 


An  organic  stricture  may  be  annular,  tortuous,  single,  or  multiple. 

In  annular,  or  ring  stricture,  the  cicatricial  contraction  involves  the  entire 
circumference.     It  may  vary  in  width  from  a  line  to  one  incli. 

In  tortuous,  or  irregular  stricture,  an  inch  or  more  of  the  urethral  canal  is 
involved. 

Two  or  more  annular  or  lateral  strictures  may  unite  to  form  a  tortuous  or 
irregular  stricture. 

The  pathology  of  stricture  of  the  urethra  is  that  of  an  inflammation  of  varia- 
ble intensity  involving  the  epithelial  and  submucous  basement  membrane  of  this 
canal,  together  with  the  deeper  tissues  of  the  corpus  spongiosum,  and  occasionally 
of  the  corpora  cavernosa.  This  process  usually'  begins  from  within,  but  may  orig- 
inate in  the  deeper  tissues  of  the  penis  and  involve  the  urethra  secondarily. 

In  a  typical  case  there  is  first  an  increased  vascularity  of  the  submucous  area, 
followed  by  emigration  of  leucocytes  and  cell  proliferation.  The  lining  membrane 
becomes  pufEy  and  swollen,  and  the  diameter  of  the  canal  is  diminished.  As  the 
acute  inflammation  subsides,  the  pufEness  disappears,  but  the  caliber  of  the  tube 
is  again  diminished  by  the  contraction  which  takes  places  in  the  newly  formed 
connective-tissue  elements   (cicatrization). 

Causes. — Among  the  causes  of  stricture,  specific  urethritis  ranks  first,  a  fact 
which  emphasizes  the  importance  of  the  early  recognition  and  j^rompt  treatment 
of  this  disease. 

Any  violence  inflicted  upon  the  urethra,  either  from  without,  as  by  a  blow 
upon  the  perinajum  or  fienis,  or  from  within,  as  by  the  reckless  use  of  instruments, 
the  lodgment  of  calculi  or  other  foreign  bodies,  may  also  cause  a  stricture. 

Chancroidal  ulcer  within  the  meatus  is  a  rare  cause  of  this  lesion. 

Location.— l^\\e  most  frequent  seat  of  organic  stricture  is  in  that  portion  of 
the  urethra  limited  behind  by  the  compressor-urethrffi  muscle,  and  in  front  by  the 
suspensory  ligament  at  the  junction  of  the  penile  with  the  perineal  urethra.  Next 
in  order  is  the  first  inch  within  tJie  meatus.  Stricture  in  the  prostatic  portion  is 
rare.  As  stated  in  the  consideration  of  diseases  of  the  prostate,  it  may  occur  in 
general  hypertrophy  of  this  organ. 

Diagnosis. — The  symptoms  of  stricture  are  a  gleety  discharge,  interference  with 
the  escape  of  urine  or  semen,  and  pain.  A  muco-purulent  clischarge  continuing 
for  several  months  is  almost  pathognomonic  of  this  lesion,  and  justifies  explora- 
tion in  order  to  determine  the  presence  of  stricture.  Interference  with  the  escape 
of  urine  from  the  bladder  when  atony  of  this  organ  and  hypertrophy  of  the 
prostate  are  eliminated  is  also  a  symptom  of  importance.  A  twisted  or  forked 
stream,  when  not  of  diminished  volume,  has  no  significance,  for  this  may  exist 
with  a  perfectly  normal  canal.  Pain  is  not  often  a  symptom  of  organic  stric- 
ture, but,  when  present,  is  not  without  value  as  an  indication  of  localized  in- 
flammation. 

No  matter  what  symptoms  may  exist,  a  diagnosis  can  only  be  arrived  at  by 
instrumental  exploration,  which  can  be  done  without  pain,  and  the  exact  location 
and  character  of  the  stricture  made  positive. 


THE    URETHRA 


565 


For  this  purpose  the  Otis  bulbous  bougie  is  invaluable.     This  should  be  made 
of  all  sizes,  commencing  with  Xo.  6  and  ending  ■nith  Xos.  "21  or  23  (IT.  S.  scale). 


Fig.  572. — Longitudinal  section  of  the  urethra,  show- 
ing the  diameter  of  the  canal  at  various  points,  a. 
Prostatic;  6.  membranous;  c,  penile  portion.  (Af- 
ter Thompson.) 


Otis'  oval-tipped  wire  bougies  for  locating  strictures  of  the  ureti 

For  practical  purposes,   every  alternate   size,   from  Xos.   6  to   23  inclusive,  mil 
suffice.     The  wire  bougies  are  thoroughly  satisfactory  instruments,  and  incapable 
of  injury  to  the  urethra  if  ordinary  care  is  taken.     The  bulbs  are  oval,  the  wire 
is  flexible,  and  is  screwed  into  the  bulb 
for  securitj'. 

In  the  effort  to  locate  a  stricture, 
the  different  diameters  of  the  normal 
urethra  at  various  points  in  this  canal 
must  be  borne  in  mind.  The  meatus 
is  least  dilatable,  and  the  membran- 
ous portion  next  in  order.  Immedi- 
ately behind  the  meatus  there  is  an 
expansion  into  the  fossa  navicuiaris, 
and  from  this  point  to  the  suspensory 
ligament  (the  jimction  of  the  penile 
and  perineal  urethra)  the  diameter 
is  about  the  same.  From  the  suspensory  ligament  to  the  anterior  layer  of  the 
triangular  ligament  the  diameter  gradually  increases.  This,  the  bulbous  portion, 
is  the  largest  part  of  the  canal.  Behind  the  membranous  portion  there  is  a  second 
expansion  in  the  prostate  (Fig.  572). 

The  patient  shoidd  be  placed  upon  the  table  or  bed  in  the  dorsal  decubitus.  In 
order  to  secure  insensibility,  from  oj  to  .51]  of  a  two-per-cent  solution  of  cocaine 
should  be  thrown  into  the  urethra  with  the  ordinary  urethral  syringe  introduced 
no  farther  than  well  within  the  meatus.  While  a  stronger  (four-per-cent)  solution 
may  be  required  and  with  safety  employed,  the  idiosyncrasy  of  each  patient  must 
be  studied  by  commencing  with  Zj  of  a  two-per-cent  solution  and  gradually  in- 
creasing the  quantity  and  strength  as  reqtiired.  In  five  to  fifteen  minutes  local 
anaesthesia  is  obtained.  A  bulb  of  medimn  size  is  selected  and  properly  warmed 
and  oiled.  The  wire  is  not  curved  in  exploration  of  the  urethra  anterior  to  the 
membranous  portion.  The  penis  shoidd  be  held  at  about  a  right  angle  to  the 
plane  of  the  body,  and,  as  the  instniment  is  being  introduced,  the  organ  should 
be  elongated  in  order  to  obliterate  any  folds  in  the  mucous  membrane.  This 
membrane  is  not  so  closely  attached  to  the  connective  tissue  of  the  corpus  spongio- 
sum but  that  it  can  be  perceptibly  displaced  up  and  down  and  dovtbled  upon  itself 
if  sufficient  force  is  applied.  If  no  stricture  of  caliber  smaller  than  the  bulb  is 
encountered,  it  wiU  glide  smoothly  and  uninterruptedly  down  to  a  point  about  five 
inches  from  the  meatus,  where  it  will  be  arrested,  having  reached  the  end  of  the 
bulbous  portion  and  lodged  in  a  pocket  just  in  front  of  the  anterior  layer  of  the 
triangular  ligament.  Withdrawing  the  instrument,  it  will  in  all  probability  return 
as  smoothlv  as  it  entered.  If,  however,  a  stricture  exists,  and  the  bulb  used  is 
about  the  size  of  the  lumen  of  the  stricture,  as  it  is  carried  into  the  urethra  a  slight 
resistance  will  be  felt.  As  the  instrument  is  withdrawn,  the  broad  shoulder  of  the 
oval  will  come  in  contact  with  the  posterior  surface  of  the  obstruction,  where  it 
win  be  arrested.  The  penis  should  now  be  allowed  to  retract,  and  the  thumb  and 
finger  of  the  left  hand  slipped  down  to  the  level  of  the  meatus,  where  the  wire 
is  grasped   and    slightly   bent.      The   instrument   is   steadily   drawn   through  the 


566  THE   URETHRA 

stricture,  and,  as  soon  as  the  resistance  ceases,  the  wire  is  again  bent  at  the  level 
of  the  meatus.  The  distance  between  the  two  points  at  which  the  wire  is  bent 
re23resents  the  extent  of  the  stricture. 

When  it  becomes  necessarj'  to  search  the  urethra  bej'ond  the  bulbous  portion, 
the  wire  should  be  bent  to  correspond  to  the  normal  curve  of  the  deep  urethra. 
The  handle  of  the  instrument  should  be  bent  in  an  opposite  direction  in  order 
to  p»revent  the  possibility  of  \  getting  the  point  of  the  bougie  turned  toward  the 
perinajum.  It  is  introduced  in  the  same  way  as  the  catheter  or  steel  sound.  When 
the  triangular  ligament  and  compressor  iirethrte  muscle  are  encountered,  b}^  de- 
pressing the  handle  toward  the  thighs  of  the  patient,  the  bulb  is  made  to  rise  out 
of  the  pocket  in  front  of  the  anterior  layer  of  the  ligament  and  to  pass  into  the 
membranous  portion.  If  a  stricture  is  present  the  resistance,  if  not  felt  as  the  bulb 
goes  through,  will  certainly  be  appreciated  as  it  is  withdrawn,  if  the  instrument 
is  large  enough.  If  the  patient  is  not  narcotized,  spasmodic  contraction  of  the 
compressor  muscle  may  arrest  the  bulb,  and,  in  a  certain  sense,  simulate  stricture. 

In  the  resistance  of  the  muscle  there  is  a  roundness,  smoothness,  and  elasticity 
which  differ  from  the  rough  surface  of  cicatricial  tissue  and  the  inelastic  grip  of 
a  stricture.  When  the  obstruction  is  felt,  the  same  method  of  measurement  and 
location  is  to  be  observed.  A  stricture  may  be  roughly  estimated  by  the  intro- 
duction of  a  catheter,  ordinary  bougie,  or  steel  sound,  but  it  cannot  be  intelli- 
gently or  satisfactorily  defined  without  the  oval  bulbs. 

Not  infrequently  it  will  be  foiuid  that  the  meatus  is  too  narrow  to  admit  a 
bulb  of  sufficient  size  to  define  the  stricture,  necessitating  division  of  the  meatus 
(meatotomy) .  This  operation  may  be  done  with  an  ordinary  scalpel  or  bistoury, 
ibut  with  nothing  like  the  exactness  and  freedom  from  pain  which  "is  secured  when 
the  urethrotome  is  emjDloyed.  The  incision  should  be  made  in  the  median  line, 
and  should  correspond  to  the  floor  of  the  urethra.  It  should  not  extend  deep 
enough  to  wound  the  artery  of  the  frajnum,  nor  should  it  be  any  deeper  than  is 
sufficient  to  admit  the  larger  bougies. 

If  the  bistoury  is  employed,  the  operator  grasps  the  glans  between  the  thumb 
and  finger  of  the  left  hand,  introduces  the  knife,  cutting  edge  downward,  a  dis- 
tance of  one  half  inch,  and  cuts  carefully  outward.  The  injection  of  cocaine  solu- 
tion into  the  tissues  of  the  part  incised  or  the  local  application  of  a  few  cocaine 
crystals  within  the  meatus  Avill  render  the  incision  along  the  floor  painless. 

The  operation  can  be  more  accurately  and  satisfactorily  done  by  the  use  of  the 
Otis  dilating  urethrotome  (Fig.  573).  It  should  be  introduced  into  the  meatus 
until  the  knife  is  about  three  fourths  of  an  inch  from  the  opening,  with  the  cut- 
ting edge  of  the  concealed  blade  turned  toward  the  floor  of  the  urethra.  The 
dilating  screw  at  the  end  of  the  instrument  is  now  turned  until  the  meatus  is 
put  fairly  on  the  stretch,  when  the  knife  is  drawn  quickly  through  and  the  division 
effected.  If  the  blades  are  too  widely  separated,  the  opening  may  be  too  deeply 
slit.  If  the  first  incision  is  not  sufficient,  this  manoeuvre  should  be  repeated. 
The  small  amount  of  bleeding,  which  at  times  follows  can  be  readily  controlled 
by  plugging  the  wound  and  the  anterior  half  inch  of  the  urethra  with  a  small 
strip  of  iodoform  gauze.  To  prevent  a  recontraction,  it  is  necessary  to  introduce 
the  straight  sounds,  at  intervals  of  from  two  to  four  days,  for  two  or  three  weeks 
after  the  operation. 

Treatment. — The  treatment  of  organic  stricture  of  the  urethra  should  he  con- 
sidered imder  two  headings:  first,  those  situated  in  any  part  of  the  urethra  ante- 
rior to  the  membranous  portion ;  and,  second,  those  of  the  membranous  urethra. 

Internal  urethrotomy  is  applicable  practically  to  all  strictures  anterior  to  the 
membranous  iirethra,  while  those  of  the  membranous  portion,  with  rare  exceptions, 
may  be  relieved  by  a  modification  of  the  same  procedure. 

External  urethrotomy,  or  "  perineal  section,"  is  indicated  in  the  exceptional 
cases  in  which  the  strictiire  is  so  tight  and  tortuous  that  a  dilating  filiform  cannot 
be  introduced  to  make  way  for  the  urethrotome;  when  a  fistula  or  abscess  compli- 
cates the  stricture,  and  when  the  cicatricial  tissue  is  so  extensive  that  recontraction 
takes  place  after  one  or  more  trials  of  the  less  radical  operation.  When  properly 
performed  it  yields  gratifying  results.     The  method  of  gradual  dilatation  by  the 


THE   URETHRA  567 

repeated  introduction  of  sounds  was  formerly  much  in  vogue,  and  even  now  is 
practiced  by  some  surgeons,  but  it  is  much  more  painful  and  requires  a  greater 
length  of  time  to  effect  a  satisfactory  result  than  with  direct  urethrotomj'  followed 
by  dilatation  with  sounds. 

Complete  divulsion  or  rapid  dilatation  of  a  stricture  is  rarely  indicated,  aud 
is  practically  an  obsolete  operation. 

Partial  divulsion  by  the  dilating  filiform  bougie  of  Banks  is  often  necessary 
as  a  preliminary  to  internal  division. 

Internal  urethrotomy  in  ordinary  cases  of  stricture  is  performed  as  follows : 
The  urethra  shoidd  be  thoroughly  irrigated  with  a  1-3000  permangauate-of-potash 
solution  or  a  saturated  solution  of  boric  acid.  This  may  be  done  in  the  manner 
directed  in  the  treatment  of  gonorrhcea.  Or  the  tip  of  an  ordinary  urethral  syringe 
may  be  pressed  'firmly  into  the  meatus  and  its  contents  expelled  until  the  urethra 
is  fully  distended,  the  fluid  being  thus  forced  into  the  follicles  and  deeper  portions 
of  the  canal.  This  should  be  repeated  four  or  five  times,  and  the  e.xcess  of  fluid 
forced  out  b}^  pressure  before  the  cocaine  solution  is  introduced.  A  very  satis- 
factory auEesthesia  can  be  effected  by  injecting  into  the  urethra  with  the  same 
syringe  from  one  to  three  or  more  drams  of  a  two-  to  four-per-eent  solution  of 
cocaine,  which  is  forced  in,  and  the  meatus  held  tightly  as  the  instrument  is  with- 
drawn to  prevent  the  escape  of  the  solution.  In  about  five  minutes  the  anaesthesia 
is  complete,  when  by  releasing  the  pressure  on  the  meatus  the  cocaine  runs  out. 
As  already  stated,  the  employment  of  this  agent  in  any  manner,  and  especially  in 
the  urethra,  should  be  made  with  care.  When  using  it  for  the  first  time  in  a 
patient,  the  smaller  quantity  should  he  tried  and  the  constitutional  effect  closely 
observed.  A  bulbous  bougie  is  next  introduced  and  the  stricture  definitely  located. 
If  the  bougie  produces  pain  and  no  constitutional  effects  have  been  observed  from 
the  cocaine,  either  the  quantity  of  the  solution  may  be  increased  or  a  three-  or 
four-per-cent  solution  employecl  in  order  to  effect  a  satisfactory  anesthesia.  The 
distance  from  the  meatus  to  the  posterior  boundary  of  the  stricture  is  now  meas- 
ured on  the  urethrotome,  beginning  at  the  point  where  the  knife  is  projected  and 
extending  toward  the  handle.  Half  an  inch  should  be  added  to  this  in  order  to 
be  sure  that  the  knife  is  carried  well  beyond  the  stricture,  and  it  is  generally 
advisable  to  indicate  this  point  on  the  instrument  by  a  small  ring  clipped  from 
a  rubljer  tube  and  slid  over  the  shaft.     It  is  now  ready  for  introduction. 

The  urethrotome  consists  of  a  shaft,  handle,  and  blades.  The  shaft  is  com- 
posed of  two  bars,  which  can  be  separated  or  closed  by  turning  a  screw  at  the 
handle,  where  there  is  also  arranged  a  dial  which  registers  the  exact  degree  of 
dilatation  by  the  separation  of  the  bars.     In  the  upper  bar  of  the  shaft  is  a  slide 


Fig.   573. — Otis'  dilating  urethrotome,  with  the  author's  cog-wheel  attacliment 


or  groove  along  which  the  knife  is  carried,  and  when  this  arrives  near  the  point 
of  the  instrument  the  blade  sinks  into  a  depression  and  disappears.  I  have  added 
to  this  instrument  a  cog-wheel  apparatus  attached  near  the  handle,  by  the  use  of 
■which  the  knife  is  carried  steadily  forward  or  backward  as  desired,  and  is  made 
to  cut  with  mathematical  precision.  In  expert  hands  this  addition  is  not  neces- 
sary, the  original  instrument  of  Otis  being  eminently  satisfactor}".  The  patient 
should  rest  upon  the  back,  with  the  legs  fully  extended,  while  the  surgeon  stands 
at  the  patient's  right  side.  With  the  bars  of  the  instrument  closed,  the  knife 
inserted,  and  the  Ijlade  concealed,  the  shaft  is  lubricated  with  glycerine  as  far  as 
it  is  to  be  introduced.  The  glans  penis  is  grasped  between  the  tlutmb  and  finger 
of  the  left  hand,  the  organ  held  in  the  same  position  as  when  the  stricture  was 
located,  and  the  instrument  with  the  cutting  .edge  of  the  knife  exactly  in  the 
middle  line  of  the  roof  of  the  canal  carried  into  the  urethra  until  the  rubber 


568 


THE   URETHRA 


ring  touches  the  meatus.  If  the  measurements  have  been  correctly  taken,  the 
blade  of  the  instrument  is  now  a  quarter  of  an  inch  beyond  the  posterior  wall  of 
the  stricture.  The  left  hand,  releasing  the  penis,  is  made  to  grasp  the  urethrotome 
and  steady  it,  while  with  the  right  hand  the  dilating  screw  is  turned  until  the 
arrow  on  the  dial  indicates  a  separation  of  the  bars  nearly  equal  to  the  diameter 
of  the  bull:)  which  located  the  stricture.  The  degree  of  resistance  felt  by  the  hand 
of  the  practiced  surgeon  will  indicate  whether  or  not  the  necessary  dilatation  is 
effected  without  consulting  the  dial.  Taking  hold  of  the  end  of  the  knife  at  the 
handle,  this  latter  instrument  is  made  to  travel  through  the  stricture  from  behind 
forward  and  accurately  along  the  median  line  of  the  roof  of  the  urethra.  As  the 
knife  advances,  the  resistance  of  the  stricture  can  be  readily  felt  as  it  is  steadily 
and  firmly  drawn  through  the  cicatrix  until  all  resistance  ceases  and  the  knife 
moves  smoothly.  Without  changing  the  position  of  the  instrum'bnt,  the  knife  is 
rapidly  pushed  back  to  its  original  position  and  the  dilatation  increased  by  one 
or  more  ti;rns  of  the  screw,  and  the  knife  again  carried  forward  and  back  as  for 
the  first  incision.  The  bars  should  now  be  still  further  separated  in  order  to 
part  any  cicatricial  bands  that  may  have  escaped  the  knife  (modified  divulsion). 
When  this  is  done,  by  reversing  the  screw  the  bars  should  be  partially  closed  and 
withdrawn.  If  the  bars  are  elosel}'  apj^roximated,  the  mucous  membrane  may  be 
caught  and  torn.  A  bulb  equal  in  size  to  the  caliber  of  the  urethra  is  now  intro- 
duced, and  this  should  pass  freely  up  and  down  the  canal.  If  it  catches  at  any 
point,  further  incision  is  required.  Finally,  a  full-size,  straight  sound  is  carried 
through  the  stricture.  The  uretlira  should  now  be  again  irrigated.  The  most 
careful  asepsis  should  be  practiced  in  urethral  surgery,  and  no  instrument  should 
be  introduced  which  has  not  been  cleansed  and  boiled  prior  to  its  use. 


Fig.   574. — Banks'  dilating  filiform  bougies. 

Haemorrhage  after  internal  urethrotomy  is  usually  slight.  When  the  incision 
has  Ijeen  made  in  the  pendulous  part  of  tlie  urethra,  it  may  be  readily  arrested  by 
turning  the  penis  up  on  the  belly,  laying  a  handful  of  cotton  or  gauze  on  the 
organ  and  strapping  it  down  by  a  bandage  carried  around  the  pelvis.  In  the  pos- 
terior portion  of  the  urethra  a  compress  of  cotton  applied  along  the  perinseum 
will  control  the  bleeding  (Fig.  575).  The  patient  should  be  put  to  bed  at  once 
and  remain  quiet  for  several  days.  Not  infrequently  in  from  two  to  twelve  hours 
after  urethrotomy,  or  after  the  introduction  of  a  sound  or  catheter,  the  patient 
is  seized  with  rigors  or  pronounced  chills  followed  by  a  considerable  rise  of  tem- 
perature. This,  the  so-called  "  urethral  fever,"  is  due  to  septic  infection  in  the 
wounds  inflicted  upon  the  canal.  When  the  temperature  rises  to  103°  F.  or  more 
it  is  a  wise  precaution  to  administer  from  two  to  eight  grains  of  acetanilide  and 
to  give  the  patient  an  alcohol  or  cold-water  sponge  bath  until  the  temperature  is 
below  100°  F.  The  repeated  introduction  of  steel  sounds  or  of  gum  bougies 
is  essential  in  the  after-treatment  of  internal  urethrotomy.  The  dilatation  should 
be  commenced  usually  on  the  second  or  third  day  after  the  operation.  If  fever 
exists,  the  use  of  the  soimd  should  be  postponed  until  there  are  no  symptoms  of 
infection:  Cocaine  anaesthesia  should  be  employed,  for,  as  a  rule,  the  reintro- 
duction  of  the  sound  is  more  painful  than  the  primary  operation.  The  quantity 
of  cocaine  used  at  this  stage  of  the  treatment  should  be  less  than  for  the  original 
cutting  operation.  The  urethra  in  the  operative  field  is  now  covered  with  a  granu- 
lation tissue  capable,  under  too  great  pressure,  of  rapid,  absorption  of  the  solution 
of  cocaine  and  of  carrying  it  into  the  system,  producing  constitutional  and  at 
times  alarming  symptoms.  When  it  has  required  two  or  three  drams  of  a  two-, 
three-,  or  four-per-cent  solution  for  the  primary  operation,  before  introducing  the 


THE   OlETHEA 


569 


I: 


sound  for  the  first  time  I  begin  -n-irh  the  injecrion  of  one  dram  of  a  two-per-cent 
solution,  earefullj  watching  for  the  symptoms  of  systemic  absorption,  gradually 
increasing  the  quantity  until  a  safe  and  satisfactory  degree  of  anasthesia  is  ob- 
tained. For  the  penile  tirethra  the  straight  sounds'  are  preferable  to  the  curved 
instruments.  Beginning  Tvith  the  proper  size,  usually  about  Xo.  17,  the  numters 
are  gradually  increased  until  the  urethra  at  all  points  is  dilated  to  its  normal 
caliber.  This  procedure  should  be  repeated  every  third  or  fourth  day  for  three 
or  four  weeks,  and  every  fifth  or  sixth  day  for  about  two  months  follo\ving.  It  is 
essential  to  keep  the  walls  of  the  incision  through  the  strictured  portion  open  by  the 
interrupted  dilatations  until  the  wounded  surface  is  covered  with  newly  formed  epi- 
thelium. Should  cystitis,  epididymitis, 
or  orchitis  ensue  after  urethrotomy,  all 
operative  measures  should  be  discontin- 
ued until  these  symptoms  disappear. 

The  prognosis  after  urethrotomy 
should  be  guarded.  Many  cases  do  not 
recur,  but  a  stricture  of  long  standing 
with  extensive  induration,  no  matter 
how  thoroughly  divided  and  carefully 
treated,  tends  to  recontract.  In  some 
instances  it  thus  becomes  necessary  to 
employ  dilatation  either  with  the  sound 
in  the  hands  of  the  surgeon,  or  with 
the  soft  bougie  if  this  duty  is  intrusted 
to  the  patient,  at  intervals  of  from 
two  to  three  weeks  or  months,  as  the 
case  may  require,  during  the  life  of 
the  patient.  In  a  certain  proportion  '"^ 
of  cases  the  stricture  will  be  found  so  ^ 
tight  that  the  urethrotome  cannot  be 
passed  through  it,  necessitating  partial 
divulsion  by  the  dilating  filiform  bougie.  This  excellent  instrument,  devised  by 
the  late  Dr.  E.  A.  Banks,  of  Xew  York,  meets  every  indication.  With  the  urethra 
cocainized  as  heretofore  directed,  it  may  be  injected  with  a  small  quantity  of 
glycerine  or  sterilized  oil  and  the  filiform  carried  into  the  meatus  and  down  the 
urethra  until  it  meets  the  obstruction.  By  careful  manipidation  it  is  made  to 
find  its  way  through  the  most  tortuous  stricture.  As  soon  as  the  filiform  portion 
is  engaged  in  the  stricture,  continued  pressure  carries  this  portion  into  the  blad- 
der, while  the  larger  dilating  portion  of  the  shaft  stretches  or  tears  the  cicatricial 
bands  sufficiently  to  admit  the  urethrotome.  This  small  instrument,  in  the  vast 
majority  of  cases  of  stricture,  accomplishes  in  skilled  hands,  in  five  to  thirty 
minutes,  a  greater  degree  of  dUatation  than  the  method  of  continuous  dilatation 
employed  by  Sir  Henry  Thompson  accomplished  in  a  week.  As  it  is  elastic  and 
readily  bends  back  upon  itself  when  an  obstruction  is  encountered,  it  is  a  perfectly 
safe  instrument  in  competent  hands.  When  fully  introduced,  the  filiform  portion 
curls  upon  itself,  producing  no  injury  to  the  bladder.  In  rare  instances,  where 
the  dilating  filiform  bougie  cannot  be  made  to  pass  beyond  the  obstruction,  external 
urethrotomy  is  demanded. 

llodified  Internal  Urethrotomy. — When  a  stricture  of  the  membranous  portion 
of  the  urethra  exists  and  a  filiform  bougie  can  be  passed  through  it  and  there  is 
no  urethro-perineal  fistula  or  abscess,  relief  from  the  obstruction  may  be  obtained 
by  this  operation.  The  stricture  is  partially  divulsed  by  the  forced  introduction 
of  the  Banks  dilating  filiform  Iwugie,  as  just  advised  in  very  tight  strictures  of 
the  pendulous  portion  of  the  urethra.  If  an  ordinary-sized  dilating  filiform  bougie 
is  not  large  enough  to  make  room  for  the  urethrotome,  it  should  be  followed  bv  a 
larger  instrument  of  the  same  kind.  As  soon  as  the  way  is  clear  for  the  urethro- 
tome, the  ordinary  straight  instrument  of  Otis  (Fig.  573)  is  carried  into  the 
urethra  tin  til  the  membranous  portion  is  reached.  Placing  the  left  hand  upon 
the  penis  over  the  pubic  arch  and  pressing  down  upon  the  body  of  this  organ. 


;.  575. — ^The  author's  method  of  compressing  the 
penile  and  perineal  urethra  to  control  hemor- 
rhage after  internal  urethrotomy. 


570  THE   URETHRA 

putting  the  suspensory  ligament  upon  the  stretch,  and  at  the  same  time  depress- 
ing the  handle  of  the  instrument  until  the  shaft  is  parallel  with  the  surface  of 
the  thighs,  the  curved  urethra  is  made  into  a  straight  channel  and  the  point 
of  the  urethrotome  with  the  slightest  possible  pressure  is  forced  through  the 
stricture  until  its  tip  rests  in  the  neck  of  the  bladder.  As  a  rule,  the  stricture 
grasps  the  instrument  in  this  position  tightly.  Without  separating  the  bars,  the 
knife  is  now  drawn  forward  and  backward  along  the  middle  line  of  the  roof  of 
this  portion  of  the  urethra,  partially  dividing  the  stricture.  If  the  bars  are  then 
separated,  in  the  majority  of  cases  the  stricture  readily  gives  way  by  divulsion  in 
the  line  of  the  partial  incision.  If  the  stricture  is  still  unyielding,  requiring 
greater  force  in  the  separation  of  the  bars  of  the  urethrotome  than  seems  proper 
to  the  operator,  a  very  slight  dilatation  may  be  made  and  the  knife  again  drawn 
through  in  order  to  make  a  deeper  incision,  and  thus  enable  the  divulsion  to  be 
compreted.  Two  oljjections  may  be  made  to  this  operation :  first,  the  danger  of 
hasmorrhage  from  the  artery  of  the  bulb  or  the  artery  of  the  corpus  cavernosum ; 
second,  its  lack  of  thoroughness  in  completely  removing  the  cicatricial  tissue.  If 
the  method  is  closely  followed,  there  is  no  possible  danger  of  haemorrhage.  The 
knife  is  used  only  in  dividing  the  most  prominent  bands  of  the  stricture — those 
farthest  from  the  vessels — the  remaining  bands  being  toi'n  through  by  the  divuls- 
ing  power  of  the  instrument.  The  arteries  which  surround  or  arch  over  the 
urethra  are  elastic  tubes  which  stretch  under  the  divulsion;  and  while  the  un- 
yielding bands  of  cicatricial  tissue  are  torn  across,  the  vessels  are  not  injured. 

I  have  employed  this  method  in  a  large  number  of  cases,  and  have  never  had 
an}'  hsemorrhage.  As  to  its  inefficiency,  necessitating  the  continued,  interrupted 
use  of  bougies  or  sounds,  the  same  may  be  said  of  many  strictures  of  the  anterior 
urethra  which  are  treated  practically  by  all  surgeons  in  the  same  manner.  More- 
over, if  a  very  long  and  dense  stricture  be  encountered,  which  does  not  yield  readily 
to  the  method  of  dilatation,  perineal  section  may  then  be  resorted  to  for  the 
radical  cure.  I  am  convinced  that  this  last-named  operation  is  performed  in  a 
great  many  eases  where  modified  internal  urethrotomy  would  give  relief  and 
satisfaction.  Hsemorrliage  from  the  deep  urethra,  as  well  as  from  the  perineal 
2)ortion  anterior  to  the  triangular  ligament,  may  readily  be  controlled  by  com- 
pression. A  large  wad  of  absorbent  cotton  is  placed  on  the  perina?um,  extending 
from  the  anus  forward  to  the  scrotum;  in  front  of  the  scrotum,  along  the  penile 
urethra,  a  second  cotton  compress  is  applied,  and  a  bandage  passed  around  the 
pelvis  in  a  figure-of-8  fashion  over  the  iliac  crests  and  around  the  hips.  In  case 
there  were  any  bleeding  backward  into  the  bladder,  the  introduction  of  a  large- 
size  sound  would  act  as  a  direct  haemostatic.  The  necessity  for  such  a  procedure 
will  never  be  indicated  when  proper  care  is  taken. 

The  after-treatment  consists  in  interrupted  dilatation  by  the  introduction  of 
straight  or  curved  sounds. 

External  urethrotomy,  or  perineal  section,  is  an  operation  for  the  relief  of 
close  organic  stricture  of  the  bulbous  or  membranous  portions  of  the  urethra 
which  cannot  be  reached  through  this  canal.  With  the  exception  of  those  cases 
where  urinary  fistula  or  chronic  abscess  exists  as  a  result  of  stricture,  the  con- 
ditions which  justify  this  operation  are  rare. 

It  is  performed  with  or  without  a  guide.  When  a  sound  or  bougie  can  be 
carried  through  the  obstruction  into  the  bladder  the  procedure  is  much  simplified. 
Without  this  guide  the  operation  is  surrounded  Avitlr  considerable  difficulty.  In 
external  urethrotomy  the  patient  is  placed  in  the  lithotomy  position,  being  pre- 
pared as  for  this  operation.  After  the  ana3sthesia  is  complete,  a  careful  and  final 
effort  should  be  made  to  carry  a  filiform  or  soft  Ijougie  through  the  stricture  and 
into  the  bladder.  If  this  cannot  be  done,  a  good-sized  sound  should  be  carried 
down  to  the  obstruction,  and  this  will  serve  to  guide  the  operator  to  the  com- 
mencement of  the  stricture. 

An  incision  is  then  made  exactly  in  the  median  line,  the  anterior  limit  being 
slightly  in  front  of  the  ascertained  commencement  of  the  stricture,  the  posterior 
extending  toward  the  anus  a  sufficient  distance.  In  making  this  incision  the 
scrotum  should  be  held  up  Ijy  an  assistant,  who  is  directed  not  to  displace  the 


THE   miETHRA 


571 


median  raphe  to  either  side.  The  legs  must  also  he  held  in  the  same  relative 
position. 

The  bleeding  is  usually  considerable,  as  the  vascular  tissue  of  the  bulb  is 
divided.  All  vessels  should  be  secured;  but  the  oozing,  which  is  general,  need 
not  retard  the  operation.  As  soon  as  the  sound  or  filiform,  at  the  anterior  margin 
of  the  constriction,  is  seen,  the  division  should  continue  along  the  guide  until 
the  healthy  urethra  is  reached  beyond  the  stricture.  If  no  guide  has  been  intro- 
duced, the  dissection  should  be  carried  back  in  the  known  direction  of  the  base 
of  the  bladder,  guided  by  the  location  of  the  prostate  with  the  finger  introduced 
into  the  rectum.  The  first  indication  that  the  canal  is  reached  behind  the  stric- 
ture will  be  a  gitsh  of  urine.  On  accotmt  of  the  obstruction,  the  urethra  between 
it  and  the  bladder  is  widely  dilated,  and  for  this  reason  is  more  readily  found. 
It  is  essential  to  the  success  of  this  operation  that  all  cicatricial  tissue  be  dissected 
out.  A  large-sized  steel  sound  should  now  be  introduced  through  the  meatus  and 
into  the  bladder.  If  any  difficulty  is  met  with  in  introducing  this  instrument,  a 
flexible  bougie  may  be  substituted.  It  is  not  advisable  to  leave  the  instrument  in 
the  urethra.  In  order  to  prevent  bleeding,  the  wound  should  be  packed  temporarily 
with  gauze,  held  in  position  by  a  T-bandage.  A  fatal  hemorrhage  occurred  in 
one  of  the  author's  cases,  the  packing  having  liecome  loose  while  the  patient  slept. 

The  urine  usually  escapes  through  the  wound  for  the  first  few  days,  and  after- 
ward partly  through  the  wottnd  and  partly  through  the  urethra.  In  rare  instances 
it  escapes  uninterruptedlj^  through  the  urethra.  The  after-treatment  consists  in 
the  introduction  of  the  sounds  or  botigies  (as  above  directed)  through  the  urethra 
as  far  as  the  neck  of  the  bladder.  This  operation  shotild  be  repeated  every  three 
or  four  days  until  the  urine  ceases  to  escape  through  the  wound,  and  once  a  week 
thereafter  for  several  months.  In  urinary  fistula  and  peri-urethral  ^abscess  the 
operation  is  practically  the  same.  The  urethra  is  opened  in  the  area  involved  and 
the  stricture  incised  and  dissected  out. 

Interrupted  Dilatation. — In  the  treatment  of  stricture  of  the  urethra  by  this 
method  there  are  required  steel  sounds  and  flexible  bougies.  Steel  sounds  are  of 
two  patterns,  the  straight  and  curved.  The  former  are  preferable  for  dilating 
strictures  anterior  to  the  memlDranoits  jjortion,  and  when  properly  constructed  and 
in  experienced  hands  they  will  suffice  for  dilatation  of  the  deep  urethra.  The 
curved  instruments  may  also  be  employed.  The  most  satisfactory  instruments  are 
those  constructed  upon  the  United  States  scale,^  which  commences  with  the  small- 


'^c^:^c^c^ijTK:  ceo 

U-.S.  Scale   -  U  NiT_  ^50  I  NCH   Diameter. 


est  steel  instrument,  -^^  of  an  inch  in  diameter,  and  increases  ^,3-  of  an  inch  in 
diameter  for  each  successive  sound  to  Xo.  25  inclusive,  equal  to  f-|  of  an  inch. 
ISTos.  1  to  S.  inclusive,  are  filiform  and  elastic  bougies. 

A  straiglit  sound  should  be  eight  inches  in  length  clear  of  the  handle,  slightly 

'  The  unit  of  the  French  scale  is  one  third  of  a  milHmetre  (about  --h  of  an  inch),  and  each  size 
up  to  Xo.  30,  inclusive,  increases  one  third  of  a  millimetre  in  diameter.  Divide  any  given  number 
of  this  scale  by  three,  subtract  the  quotient,  and  the  remainder  approximates  the  corresponding 
size  on  the  above  scale.  Thus,  No.  30  French,  divided  by  3  =  10;  30-10  =  20;  or,  No.  30,  French 
-  No.  20,  U.  S.  The  instruments  on  this  scale  are  manufactured  after  the  author's  directions  by 
Tiemaim  &  Co.,  of  New  York  City. 


572 


THE   URETHRA 


conical  from  the  tip,  back  for  a  distance  of  one  and  a  half  inches.  This  conicity 
should  increase  one  size  for  every  half  inch  for  this  distance.  Thus,  a  sound  which 
measures  N"o.  17  at  the  tii?  increases  to  No.  18  one  half  inch  back,  to  No.  19 
at  one  inch,  and  is  No.  20  at  one  and  a  half  inches  from  the  point,  and  continues 
this  size  for  the  entire  shaft. 

A  curved  sound  should  be  nine  inches  long  clear  of  the  handle.     The  curve 
shoiild  involve  only  the  last  two   inches.     The  conicity  extends  also   one  and  a 


Fig.   577. — Curved  and  straight  conical  bounds 

half  inches  from  the  tip,  increasing  one  size  for  every  half  inch  until  the  full 
size  is  reached  at  one  and  a  half  inches  from  the  point.  Thus,  an  instrument 
the  shaft  of  which  measures  No.  20,  is  17  at  the  tip,  18  at  one  half  inch,  and 
19  at  one  inch  farther  back. 

The  curve  should  be  made  to  correspond  to  that  of  the  normal  deep  urethra, 
which  is  that  of  a  circle  with  a  diameter  of  three  and  a  quarter  inches ;  "  and  the 
jjroper  length  of  arc  of  such  a  circle 
to  represent  the  subpubic  curve  is  that 
subtended  by  a  chord  two  and  three 
quarter  inches  long"^  {^^E-  S'^'S). 

Flexible  bougies  are  of  various  sizes, 
being  conical  for  two  or  three  inches, 
and  olive-pointed.  They  are  exceed- 
ingly useful  instruments,  and,  when 
warmed  before  introduction,  are  in- 
capable of  injury  to  the  urethra,  even 
when  an  unusual  degree  of  force  is 
employed.  The  black  French  bougie 
is  preferable.  The  filiform  instrument 
has  already  been  described. 

In  dilating  a  stricture  with  the 
conical  steel  sound,  the  method  of  in- 
troduction is  identical  with  that  given 
in  using  the  metal  catheter.  In  the 
interrupted  dilatation  a  mild  degree 
of  force  is  exercised,  and  the  seance  is 
repeated    on    every    second,    third,    or 


>^ 


^ 


3    k 


fourth  day.  The  length  of  the  interval  between  the  introductions  must  be  de- 
termined by  the  symptoms  in  each  case,  the  object  being  to  accomplish  moder- 
ate divulsion  at  each  sitting  without  producing  marked  inflammation.     The  sound 

'  Van  Buren. 


THE   URETHRA 


573 


should  never  be  carried  beyond  the  point  wliere  its  full  dilating  power  is  applied 
to  the  stricture.  In  this  waj^  irritation  of  the  prostatic  urethra  and  neck  of  the 
bladder  may  be  avoided  in  all  save  the  deepest  variety  of  strictures. 

The  dilatation  of  strictures  by  the  use  of  conical  steel  sounds  should  be  limited 
to  those  cases  in  which  the  stricture  is  of  sufficient  caliber  to  admit  at  least  No. 


15,  U.  S.,  and  is  narrow  or  linear  in  character,  so  that  it  may  be  made  to  give 
way  without  the  employment  of  too  great  force.  The  smaller  sounds  are  capable 
of  penetrating  the  walls  of  the  urethra  unless  they  are  used  with  great  skill  and 
carefulness,  while  the  larger  instruments  will  not,  within  the  limit  of  safety,  suc- 
ceed in  the  dilatation  or  rupture  of  a  broad  or  tortuous  stricture.  Incision  with 
the  urethrotome  is  a  safer  and  less  painful  operation,  and  the  sounds  serve  an 
admirable  purpose  in  the  after-treatment. 

In  using  the  soft  bougies  in  the  anterior  portion  of  the  urethra,  they  may  be 
passed  in  straight;  but,  when  the  deeper  portion  is  invaded,  they  should  be  curved 
as  much  as  possible,  to  correspond  to  the  subpubic  curve  of  this  canal. 

Foreign  Bodies  in  the  Urethra. — Calculi  occasionally  lodge  in  the  urethra,  and 
substances  introduced  throusrh  the  meatus — as  fragments  of  a  catheter,  etc. — may 


Fig.  5S3. — Straight  and  curved  alligator-jawed  urethral  forceps. 


require  removal  by  the  surgeon.  The  diagnosis  will  be  evident  from  the  symptoms 
of  obstruction  to  the  escape  of  urine,  by  recognition  of  the  body  by  digital  pressure 
along  the  canal,  and  by  exploration  through  the  meatus.  Stone  may  be  made  out 
by  the  grating  soimd  which  is  emitted,  or  l^y  the  sense  of  friction  upon  a  rough 


Fig.  584. — Hale's  instrument  for  removing  foreign  bodies  from  the  urethra.     (After  Linhart.) 

and  hard  surface  which  is  conveyed  to  the  fingers  along  the  sound:  A  metallic 
substance  may  also  be  recognized  by  the  peculiar  click  which  is  elicited  when  it  is 
brought  in  contact  with  the  exploring  instrument. 


574  THE   URETHRA 

Eemoval  with  cocaine  anajsthesia  may  be  effected  through  the  meatus,  or  by- 
incision  directly'  through  the  floor  of  the  urethra  at  the  point  of  lodgment.  It  is 
always  desirable  to  avoid  incision  through  the  urethral  wall  when,  by  the  use  of 
forceps  or  any  mechanism,  the  extraction  can  be  effected  through  the  meatus 
without  doing  too  great  violence  to  this  canal.  If  the  substance  is  narrow  and 
smooth,  it  may  be  seized  with  the  forceps  (Fig.  583)  and  extracted.  The  straight 
alligator  forceps,  or  the  instrument  of  Hale,  is  preferable  for  the  anterior  portion 
of  the  urethra,  while  for  the  deeper  part  the  curved  instrument  is  more  suitable. 
For  a  round  body,  the  scoop  or  curette  will  prove  more  satisfactory  (Fig.  585). 

In  using  the  forceps,  the  instrument  closed  should  be  carried  down  until  its 
beak  strikes  the  foreign  substance,  when  the  jaws  should  be  slowly  separated  and 
pushed  farther  in,  so  that  they  may  pass  between  the  lining  membrane  of  the 
urethra  and  the  body.  They  should  then  be  firmly  closed  and  cautiously  moved 
a  slight  distance  to  and  fro  in  order  to  determine  whether  the  mucous  membrane 
has  been  caught  in  the  instrument.  This  danger  will  in  great  part  be  obviated  if, 
just  at  the  moment  when  the  jaws  are  applied  to  the  foreign  substance,  the  urethra 
is  put  upon  the  stretch  by  pulling  upon  and,  elongating  the  penis.  The  canal 
should  be  lubricated  by  an  injection  of  sweet  oil.  If  stricture  exists,  urethrotomy 
may  be  necessary  before  the  substance  can  be  extracted.  In  a  case  which  came 
under  my  care,  two  strictures  were  divided  with  the  urethrotome.     From  behind 

the  first  constriction  two  calculi  were 
removed,  and  several  after  the  second 


Fig.  585. — Curette,  or  scoop,  for  the  removal  of  Fig.  586. — Calculi  ^emo^  ed  from  the  urethra, 

calculus  in  the  urethra.      (After  Van  Buren  (The  author's  case.) 

and  Keyes.) 

stricture  was  divided  (Fig.  586).  In  this  operation  a  scoop  proved  more  service- 
able than  the  forceps. 

In  a  second  operation  I  found  it  necessary  to  perform  external  urethrotomy, 
cutting  directly  do-s^Ti  upon  the  calculi  (two  in  number),  which  were  easily  re- 
moved through  the  incision.  The  direct  injection  of  cocaine  into  the  tissues  secured 
complete  anaesthesia.  The  wound  should  be  left  to  close  as  in  the  ordinary  opera- 
tion of  perineal  urethrotomy. 

Urinary  Fistula  Communicating  with  the  Urethra. — In  congenital  or  acquired 
urinary  fistula  communicating  with  the  urethra  the  following  operative  measures 
are  indicated:  When  the  fistula  opens  in  the  perinjeuin  or  lower  surface  of  the 
penile  urethra,  the  method  of  Szymanowski  offers  the  surest  prospect  of  success. 
It  is  essential  that  all  inflammation  in  and  about  the  field  of  operation  be  allayed, 
sinuses  slit  up  and  healed,  and  all  strictures  divided,  or  stretched  and  cured.  The 
bowels  should  be  well  emptied  for  two  or  three  days  before  the  operation.  For 
perineal  fistula  the  lithotomy  position  is  preferable;  the  parts  should  be  shaved 
and  disinfected.  Proceed  as  follows:  Let  the  dark  spot  at  F  (Fig.  587)  represent 
the  opening  of  the  fistula.  A  straight  incision  A  B  is  made,  passing  along  one 
edge  of  the  fistula,  extending  three  quarters  of  an  inch  each  way  from  the  open- 
ing. This  incision  passes  through  the  skin  and  superficial  fascia.  The  edge  of 
this  incision  is  raised,  and,  dissecting  away  from  the  fistula,  the  skin  is  lifted  to 
form  a  pocket,  the  bottom  of  which  is  the  dotted  curved  line  A  C  B.  and  the  lifted 
edge  or  entrance  to  this  pocket  the  straight  incision  A  F  B.  On  the  opposite  side, 
corresponding  accurately  with  the  attached  Ijottom  of  the  pocket  A  C  B,  a  curved 


THE   URETHRA 


575 


incision  A  D  B  is  made,  the  greatest  depth  of  the  flap  being  from  three  quarters 
to  one  inch.  From  this  flap,  with  a  pair  of  small  scissors  curved  on  the  flat, 
remove  the  epidermis,  except  over  an  area  amply  sufficient  to  cover  the  fistulous 
opening.     (This  area  is  represented  in  white  between  F  and  D  in  Fig.  587.) 

The  flap  A  D  B  is  now  dissected  up,  taking  with  it  a  generous  allowance  of  sub- 
cutaneous fat  and  fascia,  down  to  about  an  eighth  or  three  sixteenths  of  an  inch  of 


c;         F 


the  original  straight  incision  A  F  B,  this  attachment  being  left  to  give  it  a  suffi- 
cient blood  supply.  As  this  A  D  B  is  turned  over  toward  C,  it  hinges  on  the 
attached  edge  A  F  B,  and,  as  it  is  slipped  beneath  the  pocket  A  C  B  F,  it  will 
be  seen  that  the  undenuded  (white)  portion  suffices  to  form  the  new  floor  of  the 
urethra.  It  being  ascertained  that  the  flap  fits  accurately,  it  is  brought  out  again 
and  a  series  of  five  or  six  loops  of  fine  catgut  sutures  are  inserted  by  carrying 
the  needle  through  the  skin  one  eighth  inch  from  the  curved  dotted  line  A  C  B 
into  the  bottom  of  the  pocket,  and  beneath  the  integument,  directly  opposite  and 
through  the  free  edge  of  the  flap  A  D  B,  and  back  again,  being  brought  out  flnally 
one  quarter  inch  from  the  point  of  entrance  A  G  B  (Fig.  589).  As  these  sutures 
are  tied,  the  flap  is  inverted  and  secured.  It  now  remains  to  close  the  open  wound 
by  sutures  of  fine  linen,  which  snugly  approximate  the  lines  A  B  and  A  D  B.  The 
result  is  shown  in  A  D  B  (Fig.  590).  It  is  important  to  keep  the  bowels  from 
moving  and  the  patient  quiet  with  morphia  for  several  days.  Every  three  or  six 
hours  the  soft  jSTelaton  catheter  should  be  inserted,  the  urine  drawn  off,  and  the 
bladder  washed  out  with  four  or  five  ounces  of  warm  boric-acid  solution,  gT.  x-^j. 
On  withdrawing  the  catheter  the  end  should  be  closed  in  order  to  prevent  the 
escape  of  even  a  few  drops  of  its  contents  in  the  urethra.  The  linen  sutures 
should  be  removed  about  the  seventh  day,  and  the  use  of  the  catheter  discontinued 
only  when  the  wound  is  thoroughly  united.  Strict  asepsis  in  the  field  of  opera- 
tion and  sterilization  of  the  urine  are  necessary.  In  rare  instances  the  floor  of  the 
prostatic  and  posterior  part  of  the  membranous  portion  of  the  urethra  may  be 
destroyed,  and  the  fistula  open  directly  into  the  rectum. 

The  following  case  which  came  under  my  care  will  serve  to  illustrate  this 
form  of  fistula  :  ^ 

The  patient,  twenty-seven  years  of  age,  merchant,  came  under  my  care  in 
August,  1887.  He  came  of  healthy  stock,  and  had  had  no  sickness  of  a  serious 
character  until  1883,  when  symptoms  of  vesical  calculus  supervened,  for  which 
a  left  lateral  lithotomy  was  done  in  Aiigust,  1886.  The  stone  removed  was  reported 
to  be  the  size  of  a  hen's  egg. 

A  urethro-perineal  fistula  remained  after  this  operation,  and  from  August, 
1886,  to  August,  1887,  four  attempts  were  made  to  close  this  opening,  without 
success.  In  the  last  of  these  operations  a  drainage-tube  about  one  and  one  half 
inches  in  length  was  inserted  in  the  perineal  opening  and  left  with  the  deep  end 
in  the  urethra.     This  tube,  about  three  sixteenths  of  an  inch  in  diameter,  was 

I  Read  before  the  Ontario  Jledical  Association  at  Toronto,  June,  1888. 


576 


THE  URETHRA 


Fig.  591. — Calculus  formed 
on  a  piece  of  drainage 
tube  as  a  nucleus.  (Ac- 
tual size.) 


lost  sight  of,  the  surgeon  and  patient  supposing  it  had  escaped  externally  and 
had  been  thrown  away  with  the  dressings.  The  last  operation  was  followed  by 
considerable  pain,  which  was  persistent.  In  the  course  of  three  months  an  abscess 
opened  into  the  rectum  through  the  anterior  wall,  and  the  urine  began  to  flow 
freely  in  this  new  channel.  About  this  time  the  perineal  opening  closed  and  an 
abscess  formed  in  each  tunica  vaginalis.  These  were  incised,  and  when  I  first  saw 
the  patient  were  entirely  healed.  At  this  date  (August, 
1887)  nearly  all  the  urine  passed  through  the  rectum. 
The  patient  suffered  greatly,  and  had  to  be  kept  con- 
stantlj^  under  the  influence  of  opium. 

An  examination  per  rectum  revealed  the  presence  of  a 
stone,  the  end  of  which  was  on  a  level  with  the  anterior 
surface  of  the  rectum,  about  one  inch  beyond  the  anal 
aperture.  The  opening  was  slightly  dilated,  and  the  stone 
was  removed  through  the  rectum  by  means  of  strong  for- 
ceps. It  had  formed  in  and  upon  the  drainage-tube,  and  is  seen  in  natural  size 
in  Fig.  591.  After  consultation  with  Dr.  Edward  L.  Keyes,  it  was  determined 
to  prepare  the  patient  for  operation,  which  was  done,  and  on  September  13,  1887, 
I  operated  as  follows: 

The  patient,  in  ether  narcosis,  was  placed  in  the  Sims  position  and  a  large 
Sims  vaginal  speculum  was  introduced.  The  oisening  through  the  anterior  wall 
of  the  rectum  measured  three  fourths  of  an  inch  in  length,  with  an  irregular  width 
of  from  one  eighth  to  one  fourth  of  an  inch.  It  led  directly  into  the  urethra 
near  the  junction  of  the  membranous  and  prostatic  portions.  The  floor  of  the 
urethra  was  entirely  destroyed.  The  right  edge  (patient's  right)  of  the  opening- 
was  seen  to  be  undermined,  as  shown  by  the  dotted  surface  B  (Fig.  592). 

I  determined  to  attempt  the  formation  of  a  new  floor  to  the  urethra  by  turning 
the  mucous  membrane  of  the  rectum  into  this  jDosition.  The  operation  performed 
was  a  modification  of  the  method  of  Szymanowski.  Two  crescentic  incisions  were 
made,  as  shown  &i  A  A   (Fig.  592),  being  about  parallel  with  the  edges  of  the 


Fig.  592.  Fig.  593. 

Fig.  592. — Showing  the  anterior  wall  of  the  rectum,  and  opening  into  it  at  E,  a  sinus  from  the  membranous 
and  prostatic  urethra.  B,  Cul-de-sac,  which  undermined  the  right  margin  of  the  opening.  A  A, 
Line  of  incision,  along  which  the  flaps  were  dissected  as  far  inward  as  C  For  their  nutrition  the  two 
lateral  flaps  depended  upon  the  limit  between  the  dotted  line  C  and  the  margins  of  the  opening  E. 
D,  The  perina?um. 

Fig.  593. — Schematic.  Transverse  section  through  the  urethra  and  rectum,  showing  the  method  by 
which  the  flaps  were  turned  from  the  mucous  membrane  of  the  rectum  to  make  the  floor  of  the 
urethra,  o,  Urethra,  b,  The  right  flap  dissected  from  b'.  c,  The  left  flap  from  c'.  d,  The  silkworm- 
gut  suture  in  position  (not  entering  the  cavity  of  the  urethra) . 

opening,  but  approaching  more  closely  at  its  upjjer  and  lower  angles.  These 
incisions  went  deep  into  the  wall  of  the  rectum  and  included  the  mucous  and 
muscular  layers.  The  two  lateral  flaps  were  dissected  up,  the  left  to  within  an 
eighth  of  an  inch  of  the  edge  of  the  opening;  the  right  could  not  be  carried  so 
far  on  account  of  the  pocket  which  undermined  this  side. 

The  flaps  were  now  turned  toward  each  other  and  their  raw  edges  made  to 


THE   URETHRA  577 

meet  in  the  middle  line,  while  the  raw  surfaces  looked  into  the  rectum  and  the 
mucous  surfaces  into  the  urethra  (Fig.  593).  Sutures  of  silkworm  gut  were 
inserted,  as  shown  at  d  (Fig.  593).  These  sutures  were  about  three  sixteenths 
of  an  inch  apart,  and  were  so  inserted  that  the}'  did  not  penetrate  to  the  cavity  of 
the  urethra.  On  account  of  the  thinness  of  the  flap  at  one  point  I  was  compelled 
to  pass  one  suture  into  the  urethra. 

A  jSTelaton  catheter  was  carried  through  the  meatus  and  urethra  into  the  blad- 
der, and  through  this  the  urine  ran  out  at  intervals.  Whenever  the  urine  accu- 
mulated enough  to  create  a  desire  to  e.xpel  it,  about  six  ounces  of  Thiersch's  solu- 
tion were  thrown  in  to  dilute  it;  and  when  this,  with  the  normal  contents  of  the 
bladder,  were  evacuated,  the  same  quantity  was  thrown  in  again  and  immediately 
expelled.  In  this  way  the  wound  was  kept  practically  free  from  irritation  by  the 
urine.  Divulsion  of  the  sphincter  ani  removed  all  danger  or  annoyance  from 
spasm  of  this  organ.  The  bowels  were  kept  quiet  for  nine  days,  and  liquid  diet 
was  enforced.  The  patient  had  been  placed  on  liquid  diet  for  ten  days  prior 
to  the  operation. 

The  sutures  were  left  in  situ.  The  wound  healed  promptly,  and  the  patient 
left  for  his  home  in  three  weeks  after  the  operation.  In  April,  1888,  seven 
months  later,  he  returned,  complaining  of  slight  irritation  in  the  rectum,  and 
said  he  thought,  at  rare  intervals,  a  few  drops  of  water  escaped  into  the  bowel. 
On  examination,  three  of  the  sutures  were  still  in  position,  but  no  opening  could, 
by  most  careful  search,  be  discovered.  The  sutures  were  removed,  and  in  a  few 
days  the  patient  was  discharged.  A  second  case,  practicallj'  identical  with  this, 
was  operated  upon  in  the  same  way  and  cured. 

Congenital  Malformations  of  the  TJretlira. — In  exstrophy  of  the  bladder  the 
nrethra  is  absent,  and,  in  certain  rare  anomalies,  it  may  open  into  the  gi'oin, 
upon  the  side  of  the  glans  penis,  in  the  median  line  of  the  dorsum  penis 
(epispadias),  in  the  median  line  below  at  any  point  on  the  corpus  spongiosum 
(h3'pospadias). 

Hypospadias  is  the  most  common  of  the  congenital  deformities  of  the  urethra. 
When  the  opening  is  within  one  inch  of  the  normal  position  of  the  meatus,  oper- 
ative interference  for  the  purpose  of  establishing  a  new  urethral  canal  is  scarcely 
indicated.  It  will,  however,  in  many  instances  be  found  necessary  to  enlarge  the 
abnormal  opening  in  order  to  permit  the  free  escape  of  urine.  When  the  false 
meatus  is  so  far  back  that  in  sexual  intercourse  the  semen  cannot  be  ejaculated 
into  the  vagina,  a  plastic  operation  may  be  undertaken. 

Clinically,  hypospadias  may  be  considered  as  penile  or  penoscrotal.  In  the 
first  variety  the  false  meatus  is  more  or  less  in  front  of  the  scrotal  Junction,  while 
in  the  second  variety  the  opening  may  be  at  or  posterior  to  the  anterior  scrotal 
fold,  the  scrotum  under  these  conditions  often  being  bifid.  It  is  exceedingly 
difficult  to  correct  this  deformity  satisfactorily,  and  it  is  impossible  to  apply  any 
given  technie  to  either  of  these  two  varieties.  The  various  methods  should  be 
thoroughly  understood,  and  the  features  of  each  method  which  may  be  properly 
applied  to  a  given  case  should  be  employed. 

The  first  essential  is  to  correct  the  bowing  of  the  organ  due  to  the  contraction 
of  a  dense  band  of  fibrous  tissue  which  practically  takes  the  place  of  the  urethra. 
This  should  be  divided  transversely  in  one  or  more  places  at  the  point  of  the 
greatest  curvature  (Duplay).  When  this  is  completed,  and  the  organ  straight- 
ened, a  diamond-shaped  opening  of  raw  surface  is  the  result  (Fig.  594).^ 

Should  division  not  be  sufficient  to  permit  the  organ  to  be  thoroughly  straight- 
ened, other  contracted  fibrous  bands  should  be  sought,  and  the  more  prominent 
of  these  should  1)6  dissected  out,  and  any  remaining  portions,  together  with  the 
tight  portions  of  the  sheaths  of  the  corpora  cavernosa,  snipped  with  scissors  as  they 
are  felt  to  be  made  tense  by  the  upward  traction  on  the  glans.  This  process  is 
continued  until  the  penis  is  completely  released  and  can  be  drawn  out  straight.^ 
Should  this  be  considered  the  first  step  in  the  operation,  the  exposed  raw  surface 
should  be  closed  at  once  by  fine  linen  sutures   (Fig.  595),  and  the  procedure  con- 

iC.  H.  Mayo,  '-Journ.  of  A.  M.  A.,"  April  27,  1901. 

2  R.  Hamilton  Russell,  "Annals  of  Surgery,"  August,  1907. 


578 


THE   URETHRA 


tinired  after  an  interval  of  about  two  weeks.^     Should  a  longer  time  elapse,  the 
penis  should  be  frequently  stretched  to  "guard  against  retraction. 

The  first  important  step   in  the  construction  of  the  anterior  portion  of  the 
urethra  is  to  form  a  satisfactory  channel  through  the  glans  with  the  meatus  near 


Fig.  594. — The  contracted  bands  have  been 
divided  and  the  organ  straiglitened.  (After 
Duplay  and  Bouisson.) 


Fig.  595. — The  same,  after  tlie  incision  lias  been 
closed.  The  plastic  operation  at  the  meatus 
is  not  done  as  shown  in  the  illustration  when 
Van  Hook's  method  is  adopted. 


the  normal  position.  Simple  tunneling  through  this  part  of  the  organ  and  in- 
serting a  tube  will  not  prove  satisfactory,  since  such  a  tunnel  is  not  lined  with 
epithelium,  and  tends  to  close  spontaneously. 


Fig.  596. — A  new  urethra  for  the  anterior  half 
of  the  penis  formed  from  the  skin  on  the 
dorsum.      (After  C.  H.  Mayo  and  Van  Hook.) 


Fig.  597. — The  same,  after  the  new  urethra  1 
been  carried  through  the  tunneled  glans. 


C.  H.  Mayo's  modification  of  Yan  Hook's  method  -  of  forming  a  new  meatus 
and  the  anterior  urethra  gives  a  longer  tube,  and  in  general  should  be  given  pref- 
erence for  the  reason  that  a  sufficient  quantity  of  skin  may  be  borrowed  from  the 

'  The  method  of  forming  the  meatus  as  shown  in  Fig.  595  is  not  advised. 
^  "Journal  American  Medical  Association,"  April  27,  1901. 


THE   URETHRA 


579 


dorsum  penis  to  form  a  new  urethra  -n-hicli  will  extend  back  to  or  bej'ond  the  level 
of  the  abnormal  opening. 

A  careful  measurement  should  be  made  as  to  the  required  length  of  the  new 
tube,  and  free  allowance  should  be  made  for  the  loss  in  folding  upon  itself  this 
flap  which  is  made  into  a  tube  and  is  drawn  through  the  newly  made  meatus.  It 
is  always  better  to  allow  something  extra  in  plastic  work  on  the  skin. 

"  The  prepuce  in  cases  of  hypospadias  is  usually  redundant  and  situated  on 
the  dorsal  surface,  overhanging  the  glans  like  a  hood.  The  skin  of  the  penis  is 
noted  for  its  thinness,  having  no  adipose  tissue,  also  for  its  looseness  of  attach- 
ment and  elasticity.  Where  it  is  folded  upon  itself  at  its  cervical  attachment 
its  character  very  nearly  resembles  mucous  membrane. 

"  The  prepuce  is  extended  as  for  circumcision  and  two  incisions  are  made, 
about  one  inch  apart,  extending  from  its  free  border  to  its  attaeliment  at  the 
penile  cervix;  the  prepuce  is  unfolded,  forming  a  loop  of  thin  skin  about  two 
and  one  half  inches  in  length.  Should  this  not  be  considered  sufficient  to  reach 
from  its  attachment  to  the  hypospadiac  opening,  the  two  incisions  are  extended 
back  along  the  dorsum  of  the  penis  until  sufficient  tissue  is  obtained,  when  the 
two  incisions  are  connected  by  a  transverse  one,  and  the  flap  of  skin  lifted  but 
left  attached  to  the  cervix  by  the  inner  surface.  Several  sutures  now  close  the 
lateral  integument  of  the  penis  over  the  denuded  area  (Figs.  596,  597). 

"  The  pediculated  flaj)  of  prepiice  is  constructed  into  a  tube  with  its  skin  or 
outer  surface  inside,  by  means  of  a  number  of  catgut  sutures.  The  penis  is  tun- 
neled by  means  of  a  narrow  bistoury  or  medium  trocar  and  canula,  through  the 
glans,  above  its  groove,  along  the  penis  to  a  point  beneath  the  hypospadiac  open- 
ing, when  it  is  made  to  emerge  at  one  side  of, 
but  close  to,  the  urethra;  the  tube  of  prepuce  is 
drawn  throiagh  the  tunnel  and  sutured  where  it 
enters  the  glans,  and  also  where  it  emerges  (Fig. 
597).  At  the  end  of  ten  days  the  flap  of  pedicle 
is  cut  through  close  to  the  new  meatus.  The 
second  operation,  made  at  a  later  period,  consists 
of  a  23erineal  opening  into  the  urethra  and  inser- 
tion of  a  Jacobs'  self-retaining  female  catheter; 
this  is  the  least  irritating  and  can  be  left  as  long 
as  needed,  usually  from  five  to  eight  days.  An 
incision  at  the  termination  of  the  two  urethras 
now  admits  of  accurate  coaptation  by  sutures,  or 
the  normal  urethra  may  be  mobilized  (Beck 
method)  to  a  suiScient  extent  to  admit  of  its  in- 
sertion into  the  caliber  of  the  new  urethra,  where 
it  is  held  by  sutures  and  the  external  parts  closed 
over  this  (Fig.  598).  Occasionally  a  little  urine 
escapes  into  the  urethra  and  the  entire  canal  is  best  drained  by  passing  several  silk- 
worm strands  through  the  urethra  and  out  alongside  the  catheter  in  the  perineal 
opening.  When  union  of  the  canals  is  complete  the  drains  are  removed  and  the 
perineal  drainage  will  usually  close  itself  in  a  few  days.  Horsehair  and  fine 
catgnt  have  proved  the  best  suture  material  for  this  form  of  plastic  work. 

"  The  advantages  of  this  combined  operation  are :  1,  a  urethral  tube  of  thin 
elastic '  skin  nearly  approaching  mucous  membrane,  yet  having  no  hair  surface 
to  occasion  later  complications;  2,  a  perineal  drain  for  the  bladder,  with  a  self- 
retaining  Jacobs'  female  catheter;  3,  a  silkworm  drain  for  the  urethra;  and  4,  in 
being  a  method  capable  of  application  to  the  worst  types  of  hypospadiac  cases." 

When  the  skin  on  the  under  surface  of  the  penis  is  loose  and  redundant,  after 
the  contractions  have  been  overcome  the  following  simple  procedure  in  the  author's 
practice  succeeded  in  establishing  a  satisfactory  urethral  channel :  On  either  side 
of  the  median  line  of  the  under  surface  of  the  penis  from  the  abnormal  opening 
to  the  glans  the  epidermis  was  removed  with  scissors  for  the  space  of  about  three 
sixteenths  of  an  inch  in  breadth,  leaving  about  three  eighths  of  an  inch  of  unde- 
nuded  skin  between  the  two  parallel  furrows  of  denudation.     Passing  the  needle 


Fig.  59S.  —  Perpendicular  section, 
showing  the  new  canal  and  peri- 
neal drainage  of  tlie  bladder. 
(Mayo.) 


580  THE   PENIS 

in  and  out  through  the  undenuded  skin  just  at  the  edges  of  denudation,  fine  silk 
sutures  (interrupted)  were  inserted  in  such  a  manner  as  to  bring  the  viviiied 
surfaces  together  to  fold  into  a  cylinder  the  strip  of  integument  between  these. 
As  the  urine  was  allowed  to  escape  through  the  abnormal  opening,  infection  did 
not  occur,  and  prompt  union  was  obtained. 

In  a  second  operation,  made  three  weeks  later,  the  same  method  was  applied 
to  close  the  abnormal  opening.  The  urine  was  drawn  by  careful  aseptic  catheter- 
ization, and  this  wound  also  closed  promptly. 

Neoplasms. — Papillomata  and  fibromata  are  occasionally  met  with  growing 
from  the  mucous  membrane  of  the  urethra.  They  produce  symptoms  of  obstruc- 
tion varying  with  their  shape,  size,  and  point  of  attachment.  They  may  be  ob- 
served by  means  of  the  urethral  speculum   (Fig.  599),  or  when  deeply  situated 


Fig.  599. — Urethral  speculum  of  H.  Marion-Sinis. 

the  urethroscope  (Fig.  570)  will  establish  the  diagnosis.  The  only  treatment  is 
removal,  which  may  be  done  by  the  wire  snare  or  by  torsion  with  forcepis.  In 
extreme  cases  a  longitudinal  incision  may  be  required  in  the  median  line  of  the 
floor  of  the  penis  in  order  to  effect  removal. 

Cancer  may  originate  in  this  canal,  or  more  frequently  may  extend  here  from 
malignant  disease  of  the  prepuce  and  glans.  Dr.  Melville  Wasserman  has  re- 
ported a  number  of  cases  of  primary  epithelioma  of  the  urethra.^  Tuberculosis 
also  occasionally  attacks  the  urethra. 

The  Penis. — The  congenital  malformations  of  the  urethra  just  given  may  be 
included  with  deformities  of  the  jDenis.  The  corpus  spongiosum  is  at  times  arrested 
in  development,  while  the  corpora  cavernosa  are  fully  formed,  causing  the  organ 
to  bow  when  an  erection  occurs.  One  cavernous  body  is,  in  rare  instances,  not 
fully  formed,  and,  when  an  erection  takes  place,  the  curve  is  lateral,  with  the 
concavity  toward  the  aifected  side.  The  penis  is  occasionally  double,  with  sepa- 
rate urethrse  (Fig.  520).     In  hermaphrodites  it  is  ^udimenta^)^ 

Inflammation  of  this  organ  is  rare,  except  as  a  result  of  traumatism.  It  occa- 
sionally becomes  involved  by  the  extension  of  a  phlegmonous  or  erj^sipelatous 
process  from  the  scrotum  or  abdomen,  or  from  urethritis  and  posthitis.  The 
organ  becomes  greatly  swollen,  and  a  painful  condition  of  chordee  is  almost  con- 
stant.    Retention  of  urine  may  occur,  as  well  as  suppuration  or  gangrene. 

In  the  treatment  of  mild  inflammation  of  the  penis,  local  applications  will 
usually  prove  sufficient.  The  tendency  to  erection  should  be  controlled  by  the 
use  of  opium  or  chloral  and  potassium  bromide  in  full  doses.  When  gangrene  is 
threatened,  free  incisions  in  the  long  axis  of  the  organ  should  be  practiced. 

Wounds  of  the  penis,  involving  more  than  the  integument,  always  bleed  pro- 
fusely. Hjemorrhage  may  be  controlled  \ij  direct  comf)ression  with  a  roller,  or 
by  throwing  a  few  turns  of  an  elastic  ligature  around  this  organ  near  the  pubic 
junction.  When  the  urethra  is  divided  in  whole  or  in  part,  it  is  best  to  stitch 
the  separated  walls  together  by  close  sutures  of  delicate  silk.  Catgut,  though 
more  desirable  in  one  sense,  is  too  readily  absorbed  to  hold  the  edges  of  the  wound 
in  contact  for  a  length  of  time  sufficient  to  secure  union.  It  is  not  usually  neces- 
sary to  insert  a  catheter,  and  it  is  best  to  dispense  with  this  on  account  of  the. 
irritation  it  causes.  Before  and  after  each  urination  the  urethra  should  be  irri- 
gated without  distention.  Should  the  operation  by  direct  suture  fail,  Szyma- 
nowski's  procedure  will  close  the  fistula.  Any  tendency  to  stricture  may  be  treated 
later.     When  the  dense  capsule  of  the  corpus  cavernosum  is  divided,  this  should 

1  Epithelioma  primitif  de  I'Ur&thre,  Paris,  1895. 


THE   PEXIS 


581 


be  inchided  in  the  sutures  which  are  carried  tliroiigh  the  woimd  in  the  integument. 
A  guarded  prognosis  should  be  made  in  all  deep  injuries  of  the  penis.  Distortion 
during  erection,  and  stricture,  are  frequent  results  of  such  lesions. 

Fracture  of  the  corpora  cavernosa,  an  accident  which  occurs  in  rare  instances 
as  a  result  of  great  violence  to  the  erected  organ,  is  a  difficult  injury  to  treat.  De- 
formity', with  more  or  less  loss  of  function,  is  apt  to  ensue.  The  organ  should 
be  laid  up  on  the  abdomen,  and  kept  in  a  condition  of  as  perfect  quiet  as  pos- 
sible. Cold  applications  are  indicated,  and,  in  case  of  strangulation  from  effusion 
of  blood  or  from  any  other  cause,  free  longitudinal  incisions  may  be  necessitated. 

Carcinoma. — Epithelioma  of  the  penis  is  not  an  uncommon  affection.  It  com- 
mences as  a  small  pimple  or  erosion  on  the  mucous  surface  of  the  prepuce  or  on 
the  glans,  gradually  spreading  until,  if  left  alone,  the  entire  organ  is  involved 
and  destroyed.  The  margins  of  the  ulcer  are  indurated,  elevated,  sintious,  and 
slightly  everted.  The  induration,  as  a  rule,  is  confined  to  the  immediate  borders 
of  the  sore,  not  extending  into  the  deeper  tissues  unless  inflammation  supervenes. 
As  the  disease  progresses,  the  center  of  the  surface  becomes  studded  with  buds  of 
newly  formed  cells  and  capillaries,  giving  it  an  appearance  not  unlike  a  catdiflower 
(Fig.  600).  Ulceration  occurs  at  various  portions  of  the  mass,  and  a  dirty  equality 
of  pus  is  exuded.  The  odor  from  the  decomposing  tissues  is  peculiarly  penetrating 
and  offensive. 


Fig.  600— Circn 


iji  till    piiu-      1,1  rom  a  ca^e  in  Mount  ''inai  Hospital.) 


Within  a  period  of  time  varying  from  two  to  six  or  eight  months,  enlargement  of 
the  inguinal  glands  is  observed.  This  enlargement  may  be  inflammatory  or  metas- 
tatic. As  a  rule,  metastasis  is  not  rapid  in  epithelioma  of  the  penis,  and  induration 
of  the  glands  does  not,  on  this  account,  preclude  the  hope  of  cure  after  amputation. 

The  principal  cause  of  epithelioma  of  the  penis  is  prolonged  irritation  of  the 
glans  and  prepuce  from  retained  .secretions.  All  the  cases  which  have  come  tmder 
my  observation  have  occurred  in  patients  with  unusually  long  and  tight  prepuces.^ 
It  is  usually  met  with  in  the  middle-aged  and  old,  although  it  sometimes  occurs 
in  early  adult  life. 

'  In  an  experience  of  fifteen  years  in  attendance  at  Mount  Sinai  Hospital,  I  obsen^ed  only  one 
case  of  epithelioma  of  the  penis  in  an  individual  upon  whom  in  early  life  circumcision  had  been 
performed. 


532  THE   PENIS 

The  diagnosis  of  epithelioma  is  not  very  difficult  after  ulceration  takes  place. 
The  indurated  sinuous  and  everted  borders  of  the  ulcer,  the  red,  caulifiower-like 
appearance  of  the  mass,  and  the  steady  progress  of  the  disease  in  the  destruction 
of  all  the  tissues  in  its  path,  are  symptoms  not  met  with  in  any  other  lesion  of 
this  organ.  Warty  growths  (papillomata),  when  not  seen  early  in  their  develop- 
ment, may  at  times  simulate  epithelioma,  especially  when  these  vegetations  are 
luxuriant,  are  undergoing  ulceration,  are  covered  with  purulent  matter,  and  are 
the  seat  of  repeated  hemorrhages.  No  matter  how  widespread  the  papillomatous 
neoplasm  may  be,  at  the  outskirts  of  the  mass  will  be  found  tufts  or  minute  warts 
sufficientljr  isolated  to  be  recognized.  In  the  very  earliest  stages  of  development 
of  the  ulcer  of  epithelioma,  it  is  scarcely  possible  to  make  a  positive  diagnosis 
between  it  and  chancroid,  or  even  a  simple  ulcer  of  the  prepuce  and  glans 
penis. 

Treatment  and  Prognosis. — In  well-marked  epithelioma  of  the  penis  the  safest 
method  of  treatment  is  an  immediate  excision  of  the  neoplasm  by  amputation. 
The  line  of  amjjutation  should  always  be  wide  of  the  limit  of  the  disease.  If 
the  induration  of  the  ulcer  is  well  defined,  and  is  limited  closely  to  the  margins 
of  the  erosion,  the  am2Dutation  may  be  made  with  one  inch  of  sound  tissue  inter- 
vening. If  the  inguinal  glands  are  enlarged,  and  if  the  surgeon  has  reason  to  be 
satisfied  that  the  enlargement  is  due  rather  to  inflammatory  engorgement  than  to 
metastasis,  the  operation  is  still  advisable,  and  the  prognosis  not  altogether  un- 
favorable. The  inguinal  glands  should  be  dissected  out  at  the  same  time  as  a 
precautionary  measure.  When  metastasis  of  the.  glands  is  unmistakable,  ampu- 
tation may  he  done  to  rid  the  patient  of  the  foul  and  ulcerating  mass,  although 
a  favorable  jDrognosis  cannot  be  entertained.  In  the  earlier  development  of  the 
growth,  where  a  sufficient  extent  of  healthy  tissue  intervenes  between  the  indura- 
tion and  the  line  of  excision,  amputation  offers  a  strong  hope  of  permanent  relief. 
In  the  earlier  period  of  development  of  the  ulcer,  if  doubt  exists  as  to  its  character, 
it  is  advisable  to  administer  the  iodide  of  potassium,  together  with  proto-iodide 
of  mercury,  for  a  number  of  weeks.  The  application  of  Marsden's  paste  to  the 
ulcer  should,  however,  be  made  when  it  is  first  observed.  If  it  be  epithelial  in 
character,  the  j)aste  offers  a  strong  hope  of  cure,  and  beyond  the  temporary  incon- 
venience it  produces  no  harm. 

Operation. — Amputation  of  the  penis  may  be  performed  by  two  methods: 
(1)  simple  amputation;  (2)  ani|)utation  with  transplantation  of  the  urethra  to 
the  perinffium.  In  the  selection  of  the  method,  the  operator  must  be  guided  by 
the  nearness  of  the  disease  to  the  puljes  and  scrotum.  Ordinarily,  when  the  indu- 
ration is  limited  to  the  glans,  a  simple  amputation  ma}'  be  made  at  a  point  about 
one  inch  posterior  to  this.  If  the  line  of  amputation  must  be  chosen  at  or  very 
near  the  level  of  the  pubes,  the  second  method  will  be  preferable,  for  the  reason 
that  retraction  of  the  stump  will  always  occur,  and  the  urine  escaping  over  the 
scrotum  will  keep  up  a  constant  and  annoying  excoriation  and  condition  of  un- 
cleanliness.  In  the  operation  with  transplantation  of  the  urethra,  the  urine  is 
voided  in  the  squatting  posture,  and  escapes  freely  behind  the  scrotum.^ 

Simple  Amputation. — Having  shaved  and  thoroughly  cleansed  the  pubes,  scro- 
tum, and  penis,  throw  an  elastic  ligature  around  the  organ  at  the  level  of  the 
pubes.  If  the  line  of  amputation  is  very  near  the  ligature,  this  may  be  prevented 
from  slipping  by  transfixing  the  penis  with  a  large  needle  just  in  front  of  the 
tourniquet.  Seize  the  mass  with  a  double  hook,  and,  holding  it  steady,  with  a 
long,  thin-bladed  knife  cut  the  organ  smoothly  off  at  a  point  at  least  one  inch 
behind  the  disease.  A  tenaculum  should  be  in  readiness  to  prevent  the  erectile 
tissue  from  retracting.  The  tube  of  the  urethra  should  now  be  dissected  up  for 
half  an  inch,  and  the  tissues  of  both  cavernoiis  bodies  again  divided  on  a  level, 
with  the  point  to  which  the  dissection  of  the  spongiosum  has  been  carried.  The 
urethra  is  now  si^lit  by  passing  the  knife  through  its  roof  and  floor,  and  a  silk 
suture  carried  through  the  end  of  each  lateral  half.    A  thread  is  also  passed  through 

"  I  have  performed  this,  the  operation  of  Humphrey,  three  tirnes,  and  in  none  of  these  patients 
has  any  unpleasant  symptom  followed.  Two  of  the  cases  were  under  observation  three  years  after 
the  operation. 


THE   PENIS 


583 


the  dense  capsule  of  the  corpora  cavernosa  to  prevent  their  retraction  when  the 
elastic  ligature  is  removed.  All  vessels  -(vhich  may  be  recognized  before  loosening 
the  rubber  band  should  now  be  secured  with  catgut  ligatures,  and  the  remaining 
bleeding  points  caught  up  as  the  tourniquet  is  gradually  loosened.  The  sutures 
passed  through  each  half  of  the  urethra  are  now  carried  through  the  edge  of  the 
incision  in  the  skin  to  which  it  is  sewed.  A  simple  dressing  completes  the 
operation. 

Hitmplu-ey's  Operation. — The  elastic  ligature  is  carried  around  the  penis  close 
up  to  the  level  of  the  pubes,  as  in  the  preceding  operation,  and  the  organ  severed 
as  near  the  ligature  as  possible.  The  vessels  in  the  corpora  cavernosa  should  be 
tied  at  once.  An  incision  should  now  be  made  tlirough  the  skin  along  the  under 
surface  of  the  corpus  spongiosimi,  back  to  and  splitting  through  the  base  of  the 
scrotum,  so  as  to  expose  the  tube  of  the  urethra  for  about  two  and  a  half  inches. 
This  tube  is  carefully  dissected  out  from  its  attachment  beneath  and  between 
the  two  corpora  cavernosa  for  this  distance,  and  is  turned  do-mi  on  to  the  peri- 


FlG.  601. — Humphrey's  operation.      (From  a  case  of  the  author's  at  Mount  Sinai  Hospital.) 


UKum  through  the  slit  in  the  posterior  wall  of  the  scrotum.  The  urethra  should 
next  be  split  along  the  median  line  of  its  roof  for  a  distance  of  half  an  inch  back 
from  the  end,  and  the  edges  stitched  to  the  margins  of  the  woimd  in  the  integu- 
ment of  the  peringsum.  The  operation  is  completed  by  closing  the  posterior  slit 
through  the  scrotum,  and  stitching  the  margin  of  the  wound  in  the  skin  of  the 
anterior  wall  of  the  scrotiun  to  that  of  the  belly  at  the  root  of  the  penis,  so  as  to 
cover  in  and  include  the  stump  of  the  amputated  corpora  cavernosa.  The  appear- 
ance of  the  parts  after  this  operation  is  shown  in  Fig.  601. 

Sarcoma  of  the  penis  is  exceedingly  rare.  It  may  be  recognized  by  its  rapid 
development,  the  absence  of  glandular  enlargement,  the  general  invasion  of  the 
cavernous  bodies — in  certain  cases  producing  a  continuous  and  painful  erection 
of  the  organ — and  bv  its  resemblance  to  the  well-kno^^Ti  appearance  and  behavior 


584 


THE  PENIS 


of  sarcomatous  tumors  in  other  iDortions  of  the  body.  The  treatment  should  con- 
sist in  immediate  amputation. 

Phimosis,  or  inability  to  retract  the  prepuce  behind  the  corona  glandis,  is  a 
frequent  condition  of  childhood,,  often  met  with  in  adult  life,  and  should  always 
be  corrected  in  early  infancy.  It  is  both  a  congenital  and  an  acquired  affection, 
and  may  be  partial  or  complete.  The  prepuce  may  be  adherent  to  the  glans,  or 
phimosis  may  exist  without  adhesions,  the  opening  in  the  foreskin  being  so  narrow 
that  retraction  is  impossible.  A  prepuce  ordinarily  retractile  may  become  irre- 
tractile  as  a  result  of  any  inflammatory  process  of  the  glans  and  foreskin.  This 
condition  is  not  infrequently  met  with  in  gonorrhoea  and  with  chancroid. 

Congenital  phimosis  is  an  unfortunate  affection,  preventing  perfect  cleanliness 
by  retention  and  decomposition  of  the  retained  secretions  and  urine,  and  inducing 
a  condition  of  irritation  which  it  were  better  to  avoid  by  timely  operative  inter- 
ference. Inflammatory  or  acquired  phimosis  always  requires  careful  attention, 
and  very  frequently  a  surgical  operation,  to  prevent  gangrene  or  to  expose  a  sub- 
preputial  chancroicl. 

The  operative  measures  may  include:  (1)  amputation  of  the  prepuce  (circum- 
cision) ;  (2)  dilatation  of  the  jjreputial  orifice  with  forced  retraction;  (3)  incision 
of  the  anterior  portion  of  the  prepuce  and  retraction. 

The  first  of  these  procedures  should  be  preferred  in  all  cases  in  which  there  is 
no  inflammatory  process  present,  while  the  latter  is  advisable  in  phimosis  with 
acute  balano-posthitis. 

Operation. — In  adults,  circumcision  may  he  done  with  almost  perfect  freedom 
from  pain  by  the  proper  employment  of  cocaine.  In  children  under  six  years  of 
age,  narcosis  is  advisable,  although  in  selected  cases  local  anesthesia  may  sutfice. 

Proceed  as  follows:  Cleanse  the  parts  to  be  operated  i^pon  with  1-5000  sublimate 
solution.  Grasp  the  iipper  end  of  the  prepuce  between  the  thumb  and  finger  of  one 
hand,  make  it  tense,  and  insert  a  delicate  hypodermic  needle  between  the  mucosa  and 
the  skin  and  force  in  a  free  quantity  of  a  one-half-of-one-per-cent  solution  of 
cocaine.     Using  this  weak  solution,  it  is  not  necessary  to  employ  a  rubber  tube 


tourniquet,  although  this  may  be  used  should  the  operator  prefer.  The  cocaine 
should  be  thrown  in  well  back  beyond  the  proposed  line  of  incision,  and  having 
anassthetized  this  space  in  the  median  line  of  the  foreskin,  the  needle  should  be 
withdrawn,  reinserted  through  the  anfesthetized  zone  and  both  sides  of  the  prepuce 
thoroughly  infiltrated,  taking  special  pains  to  throw  an  extra  quantity, of  the 
solution  into  the  region  of  the  frenum. 

In  selecting  the  line  of  incision,  the  best  rule  is  to  allow  the  parts  to  assume 
their  normal  relation  and  mark  the  skin  by  repeated  small  punctures  with  the 
scalpel,  parallel  with  and  about  one  fourth  of  an  inch  anterior  to  the  outline  of 
the  corona  glandis.  The  prepuce  is  now  divided,  preferably  with  the  scissors, 
exactly  in  the  middle  line  of  the  dorsum  as  far  back  as  already  indicated  by  the  line 
of  punctures,  and  the  sides  are  trimmed  off  following  the  lines  already  indicated 
down  to  the  frenum  (Fig.  603).  The  divided  skin  will  retract  to  about  the  level 
of  the  corona,  and  the  mucous  membrane  should  next  be  folded  back  upon  itself 
(not  unlike  a  turndown  collar),  and  carefully  stitched  to  the  edges  of  the  skin 
incision  in  the  following  manner: 


THE   PENIS  585 

Four  small  ten-day  catgut  sutures  are  inserted  above  and  below  and  one  on 
either  side  directly  through  skin  and  mucosa,  and  tied  in  loops  about  six  inches 
long  to  serve  as  retractors.  While  these  are  held  fairly  taut,  intermediate  sutures 
of  the  same  material  are  inserted,  making  a  close  approximation  of  mucous  mem- 
brane to  the  skin,  as  shown  in  Fig.  604.  Should  the 
operator  prefer,  the  division  of  the  prepuce  in  the 
median  line  may  be  made  with  the  scalpel  passed 
through  on  a  grooved  director,  as  shown  in  Fig.  602. 
When  the  four  catgut  loops  are  tied,  the  ends  are 
still  left  long,  and  a  loose  roll  of  absorbent  gauze 
about  half  an  inch  thick  is  made  into  the  shape  of 
the  letter  0  and  applied  over  the  line  of  sutures,  and 
is  held  in  place  by  tying  these  four  loops  down  upon 
it.  This  serves  as  a  dressing,  prevents  oozing,  and 
keeps  the  line  of  skin  free  from  infection.  The  Fig.  604.— (.-viter  Maigaigne.) 
sutures  disappear  by   absorption,   and  the  union  is 

completed  in  from  four  to  ten  days.  When  the  prepuce  is  adherent  to  the  glans, 
the  adhesions  should  be  broken  up,  usually  with  a  dull-poiuted  grooved  director, 
and  the  foregoing  j^rocedure  carried  out. 

Dilatation  or  divulsion  of  the  prepuce  yields  a  satisfactory  result  in  )'oung 
boj's.  Circumcision  is  not  indicated,  as  a  rule,  since,  if  the  prepuce  is  enlarged, 
the  foreskin  shortens  by  a  normal  process  of  atrophy.  It  is  performed  by  intro- 
ducing the  point  of  a  small,  closed  dressing  forceps  into  the  opening  of  the  fore- 
skin, and  stretching  or  tearing  this  by  forced  separation  of  the  blades.  The  opera- 
tion is  completed  by  retracting  the  prepuce  and  breaking  up  all  adhesions.  In 
the  after-treatment  it  is  essential  to  move  the  foreskin  back  and  forth  over  the 
glans  once  or  twice  daily  to  prevent  the  reformation  of  adhesions. 

Incision  limited  to  the  anterior  half-inch  of  the  foreskin,  and  in  the  median  line 
of  the  dorsum,  is  advisable  where  the  opening  is  very  small  and  dilatation  difficult. 
Eetraction  should  be  immediately  effected. 

Ulcers  of  the  Penis. — Sores  may  occur  upon  the  integument  of  the  penis, 
usually  near  the  prepuce ;  upon  the  mucous  lining  of  the  foreskin ;  the  glans ; 
within  the  meatus;  and  along  the  urethra.  Venereal  sores  are  occasionally  met 
with  upon  the  integument  of  the  scrotum,  abdomen,  perinasum,  and  thighs.  Ulcers 
of  the  penis  only  will  be  considered  here.  They  are  divisible  into  two  classes — 
namely,  the  non-specific  and  the  specific  ulcer.  To  the  former  belong  the  sores_. 
which"  follow  abrasions  and  the  eruption  of  herpes.  They  are  more  or  less  phage- 
denic in  character,  the  extent  and  rapidity  of  the  process  of  necrobiosis  being 
due  to  the  degree  of  virulence  of  the  inoculating  micro-organism,  and  the  impov- 
erished condition  of  the  tissues  attacked.  The  chancroid  belongs  to  this  group. 
In  the  second  class  belongs  the  specific  ulcer  of  syphilis. 

Non-specific  Ulcers. — -A  simple  ulcer  of  the  penis  is  extremely  rare.  It  may 
occur  here,  as  in  other  parts  of  tlae  body,  as  a  result  of  traumatism,  or  an  inflam- 
matory process  not  due  to  the  inoculation  of  a  virus.  Thus,  the  molecular  death 
of  a  variable  extent  of  tissue  may  follow  a  simple  abrasion  if  the  part  involved  is 
not  kept  free  from  all  irritation,  and  if  there  prevails  a  condition  of  impaired 
nutrition,  in  which,  as  is  well  known,  the  tissues  yield  readily  to  the  destructive 
process.  Under  more  healthful  conditions,  an  abrasion  of  the  glans  or  prepuce 
undergoes  the  simple  process  of  repair  seen  in  similar  lesions  of  the  integument 
and  mucous  surfaces  elsewhere.  Abrasions  usually  occur  on  the  sides  of  the 
penis,  close  to  the  attachment  of  the  prepuce,  just  behind  the  corona  or  near 
the  frenum.  The  glans  is  rarely  involved,  although  the  meatus,  especially  at  its 
lower  angle,  may  be  torn.  Bleeding  sufficient  to  attract  the  attention  of  the  patient 
is  rare,  unless  extensive  laceration  has  occurred. 

The  ulcer  of  herpes  is  usually  situated  upon  the  surface  of  the  mucous  lining 
of  the  prepuce,  less  frequently  'upon  its  cutaneous  surface,  and  the  glans.  It 
begins  as  a  vesicular  eruption".  There  may  be  one  or  many,  ilultiple  herpetic 
vesicles  mav  be  scattered  or  in  clusters,  linear,  semilunar,  or  circular  in  arrange- 
ment.    In  'the  recent  state  the  herpetic  vesicle  is  round  at  its  base,  measuring 


586  THE   PENIS 

from  one  twelfth  to  one  twentj'-fifth  of  an  inch  in  width.  It  consists  of  a  thin 
investing  membrane  resting  npon  a  slightly  red  and  irritated  base,  and  containing 
a  clear,  serous  fluid,  which  often  escapes  by  rupture  of  the  membrane  before  the 
vesicle  is  observed.  Upon  the  skin  they  rapidly  dry  on  account  of  evaporation 
of  the  fluid  contents,  and  the  floor  of  the  patch  becomes  covered  over  with  a  light 
incrustation.  Upon  the  mucous  and  moist  surfaces  incrustation  does  not  occur. 
The  circumference  of  the  base  exposed  after  rupture  of  the  vesicle  is  usually  round, 
with  well-defined  walls  leading  perpendicularly  down  to  the  bottom  of  a  shallow 
excavation. 

In  typical  cases  of  genital  herpes  the  morbid  process  ends  here,  the  sore  healing 
without  suppuration.  Not  infrequently,  liowever,  the  floor  becomes  covered  with 
a  layer  of  pus,  the  walls  are  undermined  and  break  down,  forming  an  ulcer  which 
is  phagedenic  in  character.  The  character  of  the  pain  varies.  In  some  instances 
■  there  is  a  stinging,  burning  sensation  felt  in  the  part  afl'ected ;  in  others  there 
exists  total  insensibility. 

Herpes  is  a  neurosis  due  to  a  local  irritation  of  the  nerve  terminations  in  the 
part  attacked.  In  some  instances  a  severe  neuralgia  of  the  branches  of  the  sacral 
or  lumbar  plexuses  exists  at  the  time  of  the  eruj)tion  on  the  glans  and  prepuce. 
Uncleanliness  is  a  frequent  cause  of  this  disease.  Any  irritation  of  the  glans  or 
prepuce  may  induce  it,  and  one  attack  is  apt  to  be  followed  by  a  second. 

In  mild  and  ordinary  cases  it  runs  its  course  in  from  ten  days  to  two  or  three 
weeks.  In  other  forms,  especially  when  infection  occurs,  it  may  last  for  a  nuinber 
of  weeks,  and  is  iTSually  complicated  by  lymphangitis  and  adenitis. 

Phagedenic  ulcer  of  the  genital  organs  was  formerly  held  to  be  the  result  of 
the  inoculation  of  a  s|)ecific  poison — the  virus  or  micro-organism  of  "  chancroid  " ; 
but,  since  ulcers  which  in  appearance  and  behavior  do  not  differ  from  the  so- 
called  chancroidal  ulcer'  have  been  produced  by  inoculation  with  the  infectious 
material  taken  from  the  pustules  of  acne,  from  gonorrhoeal  pus,  etc.,  the  spe- 
cific nature  of  this  virus  cannot  be  maintained.  Even  the  specific  ulcer  of  syph- 
ilis will,  as  a  result  of  repeated  and  prolonged  irritation,  take  on  a  phagedenic 
character. 

This  ulcer  results  most  frequently  from  direct  contagion,  the  virus  being  lodged 
in  an  abrasion  of  the  integument,  prepuce,  or  glans.  The  period  of  incubation — 
that  is,  the  length  of  time  between  the  date  of  the  contact  and  the  recognition 
of  the  sore — will  vary  in  different  individuals.  It  has  been  seen  within  twenty- 
four  hours,  and,  in  rare  instances,  as  much  as  twenty  days  have  elapsed.  In  a  very 
large  majority  of  cases  the  infiammation  is  observed  within  the  first  nine  days 
after  the  inoculation.  The  rapidity  of  its  appearance  depends  chiefly  upon  the 
thoroughness- with  which  it  is  brought  into  contact  with  the  tissues  in  an  abrasion, 
and  the  condition  of  the  tissues  at  the  time  of  the  invasion.  The  ulcer  is  usually 
located  on  the  side  of  the  penis,  just  behind  the  corona  glandis  at  the  preputial 
attachment,  at  the  points  where  abrasions  are  most  frequent.  It  ma}^  be  on  the 
cutaneous  surface  of  the  prepuce,  upon  the  body  of  the  penis,  the  scrotum,  or 
within  the  meatus.  There  may  be  one  or  more,  owing  to  the  number  of  abrasions 
and  the  distribution  of  the  virus.  A  single  ulcer  may  result  from  the  confluence 
of  several  contiguous  points  of  inoculation.  It  is  first  noticed  as  a  light  redness 
or  flush,  usually  circular  or  elliptical  in  shape,  or,  if  the  abrasion  is  irregular  in 
outline,  it  will  conform  to  this.  Within  a  few  hours  after  the  appearance  of  the 
redness  its  center  becomes  elevated  and  a  pustule  is  formed,  which  soon  breaks 
down,  discharging  a  small  quantity  of  matter. 

If  the  sore  is  not  seen  early,  the  pustule  may  escape  observation.  When  the 
inoculation  occurs  upon  a  surface  denuded  of  its  mucous  membrane  or  epidermis, 
a  pustule  is  not  formed.  The  walls  of  a  phagedenic  ulcer  are  usually  precipitous. 
At  times  the  superficial  layers  of  the  skin  resist  disintegration  longer  than  the 
deeper  layers  and  subcutaneous  tissues,  giving  the  edges  an  undermined  appear- 
ance. It  tends  to  spread  in  width  rather  than  in  depth,  although  in  a  certain 
]n-oportion  of  cases  extensive  destruction  of  tissue  may  occur  in  all  directions. 
The  floor  of  the  ulcer  is  covered  with  a  creamy  pus  and  the  broken-down  tissues 
in  various  stages  of  decomposition.     A  small  quantitj'  of  matter  of  creamy  con- 


THE   PEXIS  587 

sistence  may  be  removed  witli.  a  pellet  of  cotton.  A  membrane  or  film  of  a  yellow- 
ish-brown color  usually  adheres  to  the  floor  with  considerable  tenacity. 

A  zone  of  redness  extends  along  the  edges  of  the  ulcer  in  advance  of  the  tissue 
destruction.  In  many  \dcers  this  is  not  more  than  a  line  in  width.  If  the  sore 
is  subjected  to  irritation,  the  inflammatory  redness  and  induration  may  spread 
widel}'  into  the  surrounding  tissues. 

Pain,  which  is  always  present,  varies,  as  a  rule,  with  the  extent  of  the  inflam- 
matory process. 

In  a  t}-pical  phagedenic  ulcer  of  the  jienis,  lymphangitis  and  adenitis  of  the 
inguinal  glands  are  always  present  in  a  varying  degree.  In  the  simpler  forms 
adenitis  does  not  occur,  although  the  lymphatic  channels  in  the  neighborhood 
of  the  sore  may  be  involved.  Inguinal  adenitis  or  bubo  is  always  a  painful  com- 
plication. It  may  be  lateral  or  bilateral.  If  the  sore  is  in  the  median  line,  or  if 
there  are  ulcers  on  both  sides,  both  groups  of  glands  will  be  aifected.  Suppuration 
of  the  inguinal  bulro  of  phagedenic  ulcer  is  not  uncommon.  The  violence  of  the 
inflammatory  process  here  is  subject  to  the  same  conditions  as  given  for  the  primary 
idcer.  One  or  more  glands  may  be  involved  and  suppurate.  In  severe  adenitis 
the  inflammation  extends  to  the  tissues  immediatel}^  surrounding  the  glands.  The 
mass  appears  as  one  large  swelling,  over  which  the  integument  is  red  and  oedema- 
tous,  and  to  which  it  is  adherent.  Phagedenic  bubo  is  apt  to  follow  a  virulent 
phagedenic  ulcer  of  the  penis. 

Treatment. — Simple  ulcer  of  the  penis,  if  left  without  interference,  usually 
heals  within  a  few  weeks;  the  ulcer  of  herpes  is  usually  more  obstinate.  The 
process  of  repair  may  be  greatly  facilitated  by  a  careful  removal  of  all  sources 
of  irritation.  Strict  cleanliness  is  essential,  no  matter  what  form  the  idcer  may 
assume.  Finally,  powdered  aristol,  applied  t-no  or  three  times  daU}-,  affords  pro- 
tection and  aids  in  the  absorption  of  moisture. 

In  addition  to  the  foregoing,  it  is  essential  to  keep  the  sore  uncovered  by  the 
prepuce,  which  should  be  worn  back  behind  the  corona.  Circumcision  may  at 
times  become  necessary  to  obtain  a  permanent  cure.  If  the  simpler  remedies 
just  given  do  not  succeed,  the  local  use  of  the  nitrate-of-silver  pencil  is  indicated. 

In  phagedenic  ulcer,  as  a  rule,  more  vigorous  measures  are  necessary.  The 
severit}'  in  local  treatment  will  dej^end,  however,  upon  the  rapidity  of  molecular 
death  in  the  tissues.  If  its  progress  is  slow,  and  the  inflammation  mild  in  char- 
acter, recovery  may  be  brouglit  about  by  the  treatment  laid  down  for  simple  and 
■herpetic  ulcer,  If  within  the  first  few  days  of  its  appearance  the  spread  of  the 
sore  is  rajjid,  or  if,  when  first  brought  to  the  notice  of  the  physician,  it  is  more 
than  a  quarter  of  an  inch  in  diameter,  and  the  zone  of  redness  spreads  well  out 
into  the  tissues,  it  should  be  treated  as  follows:  By  the  introduction  of  a  delicate 
hypodermic  needle  through  the  sound  tissues,  after  which  its  point  should  be 
carried  under  the  base  of  the  ulcer,  from  ten  to  twenty  minims  of  a  one-per-cent 
solution  of  cocaine  should  be  injected,  by  which  means  complete  anesthesia  may 
be  secured.  The  pus  should  now  be  removed  from  the  bottom  of  the  sore  with  a 
pellet  of  absorbent  cotton  on  the  end  of  a  small  piece  of  wood.  ■  The  parts  imme- 
diately about  the  ulcer  should  be  coated  over  with  vaseline  or  oil,  to  protect  them 
from  excoriation.  A  small  quantity  of  carbonate  of  soda  should  be  on  hand  to 
neutralize  any  excess  of  acid.  In  applying  pure  nitric  acid,  the  ulcer  should,  if 
possible,  be  held  so  that  it  will  contain  the  acid  without  letting  it  run  over  the 
edges.  It  is  best  applied  by  means  of  a  wooden  match  or  toothpick  dipped  in 
the  acid,  and  the  point  immediately  carried  into  the  floor  of  the  ulcer.  It  should 
be  conveyed  into  every  portion  of  the  sore,  and  allowed  to  remain  in  contact  with 
the  virus  for  one  or  two  minutes.  Tlie  excess  may  now  be  soaked  out  with  the 
cotton  pellets,  and  the  ulcer  filled  with  soda.  A  piece  of  lint  moistened  in  vaseline 
will  serve  as  a  dressing.  "\Ylien  nitric  acid  cannot  be  had,  the  actual  caittery 
should  be  employed. 

Iodoform  should  not  he  used,  on  account  of  the  disagreeable  odor. 

When  phagedenic  ulcer  occurs  beneath  an  irretractile  prepuce,  this  should  be 
incised  and  the  sore  treated  as  above.  Ulcer  of  the  meatus  should  also  be  burned 
with  nitric  acid.     Complete  rest  is  essential,  and  constitutional  measures  looking 


588  THE   SCROTUM 

to  the  improved  nutrition  of  the  tissues  are  strongly  indicated.  If  suppuration 
occurs  in  the  glands  of  the  inguinal  region,  free  incision  should  be  made  and  free 
drainage  established.  Phagedenic  bubo  should  be  treated  in  the  same  manner  as 
the  phagedenic  ulcer.  Chronic  adenitis,  in  -which  the  glands  are  discharging  at 
varj'ing  intervals,  is  rarely  cured  without  a  thorough  extiriDation. 

Scrotum. — ^¥ounds  of  the  scrotum  should  be  treated  as  similar  lesions  else- 
where. On  account  of  the  great  vascularity  of  the  tissues,  repair  is  usually  rapid. 
The  contractility  of  the  dartos  and  cremaster  muscles  .will  prevent  early  union 
unless  the  stitches  are  closely  applied.  If  the  testicle  is  protruded,  it  should  be 
disinfected  with  1-10,000  sublimate,  returned  to  its  normal  position,  and  the  cavity 
of  the  tunica  vaginalis  also  waslied  out  with  the  sublimate  solution.  In  closing 
the  wound  with  catgut  sutures,  the  edges  of  the  opening  in  the  tunica  should  be 
included.  A  small  catgut  drain  may  be  inserted  into  the  cavity  and  emerge  at  the 
lower  angle  of  the  incision. 

Contusions  should  be  treated  by  rest  in  the  horizontal  posture,  cold  applications 
and  mechanical  support  beneath  the  posterior  aspect  of  the  scrotum. 

(Edema  of  the  scrotum  occurs  with  general  anasarca  and  with  ascites.  The 
integument  is  tense,  pale,  and  doughy;  pits  upon  pressure,  and,  after  puncture 
with  the  hypodermic  needle,  a  clear,  watery  serum  escapes.  Besides  the  indica- 
tions for  constitutional  treatment  directed  to  the  disease  proper,  puncture  with 
the  lancet  in  several  points  will  temporarily  relieve  the  tension  and  danger  of 
gangrene. 

Eczema  and  other  cutaneous  lesions  of  the  scrotum  do  not  demand  especial 
consideration.  The  same  general  principles  of  treatment  apply  with  equal  force 
to  all  the  cutaneous  surface.  The  prognosis  is  unfavorable  on  account  of  the 
irritation  to  which  this  organ  is  subjected  from  friction  with  the  clothing  and 
thighs,  and  especially  owing  to  the  peristaltic  movements  of  the  dartos  and  cremas- 
ter muscles. 

Cysts,  due  chiefly  to  the  retention  of  sebum,  are  occasionally  seen  in  the  scro- 
tum. Tliey  are  usually  situated  near  the  raphe,  or  laterally  and  posteriorly  upon 
the  base  of  the  scrotum.  When  large  enough  to  cause  inconvenience,  incision 
and  extirpation  of  the  sac  are  demanded. 

Enjsipelas.  although  rare  in  this  portion  of  the  body,  is  met  with,  and  is  often 
obstinate  under  treatment.  Gangrene  is  one  of  the  chief  dangers,  and  must  be 
guarded  against  b}^  free  incision  as  soon  as  the  tension  is  great.  Phlegmon  of  the 
scrotum  should  he  treated  by  warm  applications,  poultices,  etc.,  and  iDy  early  in- 
cisions to  relieve  tension  and  give  escape  to  septic  matter.  Free  drainage  and 
sublimate  irrigation  are  indicated. 

Elephantiasis  scroti,  comparatively  of  rare  occurrence  in  the  temperate  and 
colder  zones,  is  frequently  met  with  near  the  equator;  and  in  some  of  the  West 
Indies  and  the  islands  of  the  South  Pacific  Ocean  it  occurs  with  great  frequency. 

The  pathology  of  this  form  of  connective-tissue  hyperplasia  has  been  given. 
The  only  treatment  is  extirpation  with  the  knife.  No  fixed  rule  of  operating 
can  be  laid  down.  The  penis  is  at  times  buried  in  the  neoplasm,  and  should  be 
carefully  dissected  out.  The  incisions  should  be  made  so  as  to  give  a  cutaneous 
flap  in  front  and  behind  sufficiently  large  to  contain  the  testes  and  cord  without 
pressure  after  the  connective-tissue  new  foranation  lias  been  dissected  out.  When 
the  penis  is  included  in  the  new  growth,  the  integimient  should  be  saved,  to  cover 
this  organ.  If  this  cannot  l^e  done,  flaps  may  be  turned  from  the  thighs  and 
alxlomen. 

The  haemorrhage  in  this  procedure  may  be  controlled  by  working  between 
fixation  forceps,  or  by  the  adjustment  of  an  elastic  tourniquet  around  the  scrotunr 
near  its  attachment  to  the  perinaeum. 

Fig.  605  represents  a  typical  case  of  this  affection  which  I  successfully  removed 
in  two  operations,  with  ten  days'  interval,  in  1893.  The  patient,  a  negro  fisher- 
man from  Bermuda,  is  entirely  well.  Tlie  entire  scrotum,  testicles,  and  penis 
were  removed. 

Angeioma  of  the  scrotum  is  rare,  and  demands  treatment  similar  to  that  advised 
in  the  chapter  on  these  vasciilar  formations. 


THE   SCROTUM 


589 


Epithelioma  is  more  frequently  seen  than  either  of  the  foregoing  neoplasms, 
and  calls  for  immediate  excision.  The  so-called  chimney-sweep's  cancer  is  often 
located  on  the  scrotum. 

Fistulce,  or  sinuses  of  the  scrotum,  ma)-  be  caused  by  abscess  of  the  tunica 
vaginalis  testis,  or  by  any  lesion  of  the  testicle.  Abscess  of  the  periaseum  or 
urinary  fistula  may  also  cause  fistula  of  the  scrotum.  Stony  concretions  are  occa- 
sionally met  with  in  tistulse  of  the  scrotum  through  which  the  lu'ine  makes  its 
escape. 

The  treatment  should  be  directed  to  a  relief  of  the  cause  of  the  fistulous  tracts. 
If  this  is  accomplished,  the  sinuses  should  be  laid  open  and  allowed  to  close  by 
granulation. 

Eamatoma. — Extrarasation  of  blood  may  occur  either  in  the  timica  fimiculi, 
in  the  tunica  vaginalis  testis,  or  in  both.     In  the  former  it  may  be  diffuse  or 


-Elephantiasis  of  scrotum  and  penis.      >*ative  of  Bermuda. 
(The  author's  case.) 


Cured  by  complete  ablation. 


circumscribed.  It  is  usually  diffuse,  the  extravasation  extending  from  the  abdom- 
inal opening  to  the  epididymis.  'WTien  only  a  portion  of  the  sheath  is  involved, 
the  hsematoma  is  generally  confined  to  the  upper  segment. 

The  chief  causes  of  extra^'asation  are  rupture  of  one  or  more  vessels  by  direct 
traumatism,  or  by  overdistention  from  prolonged  strain,  which  retards  the  return 
circulation,  causing  rupture  of  a  vein. 

Hajmatoma  of  the  timica  vaginalis  testis  is  rare,  except  as  a  complication  of 
chronic  periorchitis  serosa   (hydrocele)   or  direct  violence. 

The  diagnosis  of  hematoma  in  either  of  these  positions  depends  upon  its  sud- 
den development,  the  tendency  to  enlarge  progressively,  and  pain  from  the  sudden 
distention.  The  timior  is  not  translucent.  The  exact  nature  may  be  determined 
by  aspiration. 

Serous  effusion  (hydrocele)  into  the  sheath  of  the  cord  or  testis  progresses 
slowly  and  painlessly.  The  tumor  is  transhicent.  Exploration  with  the  hypo- 
dermic needle  and  syringe  is  a  safe,  painless,  and  positive  means  of  diagnosis. 

Hernia  may  be  eliminated  by  a  consideration  of  the  history  of  the  case  and 
the  absence  of  impulse  in  the  tumor  upon  coughing. 

Treatment. — Ha^matocele  may  be  treated  by  the  expectant  method,  or  by  surgi- 
cal interference. 


590 


HYDROCELE 


Fig.  606. — Hydrocele 
of  the  tunica  vagi- 
nalis testis.  (After 
Linhart.) 


Simple  and  limited  extravasation  requires  rest  in  the  dorsal  decubitus,  and 
the  ice-bag  locally.  After  the  hsemorrhage  is  arrested,  absorption  may  be  expe- 
dited by  judicious  and  well-applied  pressure  by  strapping.  When  the  extravasa- 
tion is  extensive,  an  incision  should  be  made  under  strict  antisepsis,  the  clot  turned 
out.  the  bleeding  point  ligated,  drainage  secured,  and  the  wound  closed.  Death 
has  followed  in  some  instances  where  operative  procedure  has  been  too  long 
delayed. 

Hydrocele  and  Spermatocele 

Hydrocele  (periorchitis)  is  a  term  employed  to  denote  an  accumulation  in  the 
sac  of  the  testicle  of  a  serous  fluid  (Fig.  606).  It  may  be  an  acute  or  a  chronic 
affection.  Tlae  fluid  contents  may  be  contained  in  a  single  sac, 
or,  as  occurs  in  rare  instances,  there  may  be  adhesions  of  con- 
tiguous surfaces  to  each  other  in  one  or  more  places,  holding 
the  fluid  in  two  or  more  separate  cavities. 

Acute  hydrocele  of  the  tunica  vaginalis  testis  may  occur 
from  any  acute  inflammatory  process  of  the  epididymis  or  testis. 
The  serous  niembrane  appears  red  and  injected,  the  capillaries 
enormously  distended  and  filled  with  blood.  The  surface  is 
less  smooth  than  normal,  the  epithelium  gradually  disappears, 
and  emigration  of  leucocytes  occurs.  A  soft,  pinkish,  elastic 
substance  is  deposited  upon  the  surface  of  the  membrane.  Simi- 
lar flalry  masses  are  also  to  be  found  in  the  fluid  contents. 
Acute  hydrocele  is  usually  accompanied  by  pain,  rarely  goes 
on  to  suppuration,  and  disappears  with  the  inflammatory  proc- 
ess which  precipitated  it.  The  diagnosis,  if  necessary,  can  be 
confirmed  by  careful  exploration  with  a  very  fine  aseptic  as- 
pirating needle.  The  treatment  is  complete  rest  of  the  part 
involved. 

Chronic  hydrocele  is  by  far  the  most  frequent  form  which  comes  under  the 
observation  of  the  surgeon.  It  occurs  at  all  times  of  life,  and  seems  to  have  no 
preference  for  one  side  or  the  other,  but  frequently  involves  both  serous  cavities. 
It  develops  slowly,  shows  no  tendency  to  disappear  spontaneously,  and  may  attain 
tremendous  proportions. 

The  astiology  of  this  disease  is  not  satisfactorily  explained.  It  is  frequently 
found  occurring  with  chronic,  subacute  inflammation  of  the  epididymis  or  testicle, 
but  as  often  exists  when  no  inflammatory  lesions  can  be  determined.  The  walls 
of  the  sac  in  most  cases,  and  in  all  cases  of  long  duration,  appear  thicker  than 
normal,  showing  a  proliferation  of  new  connective  tissue,  and  frequently  there  is 
much  induration.  In  rare  instances  calcareous  and  even  osseous  deposits  have 
been  noticed.  The  epithelial  covering  is  but  little  impaired.  It  is  whiter  than 
normal,  but  retains  its  peritoneal  gloss.  The  quantity  of  fluid  contained  in  the 
sac  varies  considerably,  at  times  reaching  a  gallon  or  more.  It  is  pale  straw  or 
amber-colored,  and  may  be  greenish-brown  or  chocolate  color  and  opaque.  Pus  is 
not  j)resent  unless  some  septic  infection  has  occurred.  It  is  neutral  or  slightly 
alkaline  in  reaction,  and  the  specific  gravity  varies,  being  usually  from  1.020  to 
1.026.  When  the  fluid  is  dark  brown  or  red,  it  contains  blood,  due  to  rupture 
of  small  vessels  upon  the  vascular  granulation  tissue  which  has  developed  upon 
the  surface  of  the  meralDrane. 

The  symptoms  of  the  disease  are  little  more  than  a  gradual  accumulation  of 
fluid,  the  enlargement  showing  first  in  the  lower  part  of  the  scrotal  sac  and 
extending  upward.  Pain  is  rarely  present  in  chronic  hydrocele.  As  the  fluid 
accumulates,  the  testicle  is  generally  pressed  upward  and  backward. 

In  the  diagnosis  of  this  affection  it  is  important  to  exclude  the  presence  of 
hernia,  which  may  complicate  it.  When  the  hydrocele  is  small  and  occupies  the 
lower  portion  of  the  scrotal  sac,  differentiation  is  easy;  but  when  it  is  of  large 
size,  extending  as  high  as  the  external  ring  and  lying  in  front  of  the  spermatic 
cord,  differentiation  is  not  so  easy.  It  is  important  to  bear  in  mind  that  the 
history  of  a  hernia  is  that  of  a  swelling  appearing  first  along  the  inguinal  canal 


HYDROCELE  591 

and  then  out  through  the  external  ring,  gradually  extending  downward  in  the 
direction  of  the  testicle,  and  that  a  hydrocele  Ijegms  below  and  extends  up.  The 
introduction  of  the  finger  into  the  external  ring  and  the  absence  of  any  impulse 
on  coughing  will  exclude  hernia.  Holding  a  bright  light  upon  the  opposite  side 
of  the  scrotal  sac,  the  serous  fluid  of  a  hydrocele  becomes  translucent,  while  a 
hernia  would  obscure  all  light.  A  hydrocele  could  scarcely  be  mistaken  for  a  vari- 
cocele, the  peculiar  wormlike  feel  of  this  latter  condition  clearly  pointing  to  its 
recognition.  A  varicocele  disappears  with  the  recumbent  posture.  Lastly,  a  posi- 
tive diagnosis  can  be  made  by  a-spirating  with  an  aseptic  and  ver}'  fine  needle. 
Even  if  an  error  were  made  and  an  intestine  ptmctured  by  this  needle,  no  harm 
would  result. 

The  treatment  of  chronic  hydrocele  has  been  greatly  simplified  in  modern 
practice.  In  the  vast  majoritj^  of  cases  of  ordinary  size,  containing  less  than  one 
pint  of  fluid,  the  tumor  can  ]ye  cured  by  the  method  of  Levis.  The  anterior  aspect 
of  the  tumor  should  be  thoroughly  cleansed  with  soap  and  water  and  a  little 
mercuric-chloride  solution.  In  an  area  one  inch  in  diameter,  with  a  delicate 
hjijodermie  needle  inject  three  to  ten  minims  of  a  one-per-cent  solution  of 
cocaine.  Through  this  ansesthetized  area,  after  grasping  the  scrotum  to  make 
it  as  tense  as  possible,  is  thrust  a  trocar  and  cantda  which  have  Just  been  taken 
out  of  the  boiler.  This  canula  should  be  threaded  in  order  to  fit  the  screw  tip 
of  an  ordinary  large-size  hypodermic  SATinge.  As  soon  as  the  point  of  the  trocar 
and  canula  pass  freely  into  the  cavity  of  the  sac,  the  trocar  is  withdrawn  and  the 
fluid  allowed  to  escape.  Gentle  pressure  applied  to  the  sac,  taking  pains  not  to 
allow  the  canula  to  be  extruded,  will  empty  all  but  a  few  drops  of  flitid.  The 
next  step  in  the  operation  is  the  injection  of  licjuid  carbolic  acid,  ninety-five  per 
cent  pure.  The  quantity  to  be  thro^vn  in  varies  with  the  size  of  the  tumor,  twenty 
minims  for  a  sac  containing  two  to  six  oimces,  gradually  increasing  to  as  much 
as  sixty  minims  for  a  sac  containing  a  pint.  Care  should  be  taken  not  to  carry 
any  air  through  the  syringe  into  the  cavity.  The  fluid  having  been  evacuated  and 
the  proper  cjuantity  of  carbolic  acid  placed  in  the  syringe,  the  thread  is  now 
screwed  iato  the  corresponding  threads  of  the  canula,  a  little  clean  vaseline  is 
spread  upon  the  scrotum  around  the  needle  puncture  to  prevent  any  possible 
leakage  of  acid  on  the  integument,  and  the  contents  of  the  syringe  forced  in. 
When  the  canula  is  withdrawn,  gentle  massage  of  the  scrotum  is  practiced  tmtil 
the  injected  carbolic  acid  has  been  brought  into  contact  with  every  part  of  the 
tunica  vaginalis  testis.  Strange  to  saj',  this  operation  is  almost  entirely  free  from 
pain,  and  in  many  instances  I  have  performed  it  as  above  described,  the  patient 
not  knowing  when  the  instrument  was  introduced  or  when  the  carbolic  acid  was 
injected.  Xo  dressing  is  required,  and,  while  it  is  l^est  for  the  patient  to  remain 
quiet  for  at  least  twentA'-four  hours  after  the  operation,  I  have  in  a  number  of 
instances  operated  upon  laboring  men  who  would  come  into  the  clinic  from  their 
work  and  return  to  it  afterward  with  the  loss  of  only  one  hour.  If  properly  done, 
this  operation  should  cure  about  seventy'-five  per  cent  of  all  cases  of  hydrocele  at 
a  first  injection.  Wlien  it  fails,  it  should  be  carefidh'  repeated,  increasing  or 
diminishing  the  quantity  of  acicl  thrown  in  as  is  necessary  to  insure  a  perfect 
result.  It  is  important  that  the  strictest  asepsis  be  carried  out,  since  the  intro- 
duction of  any  septic  organism  would  produce  a  painful  process  of  suppuration 
not  without  danger  to  the  patient.  Twenty-four  or  forty-eight  hours  after  this 
operation  the  scrotum  appears  as  large  as  ever,  is  heavy,  and  seems  solid  or  doughy 
to  the  feel.  After  a  week  or  ten  days  it  begins  to  decrease  in  size,  and,  since  the 
epithelial  lining  which  furnished  the  serum  has  been  destroyed  by  the  injection, 
it  does  not  again  retUl  with  fluid,  but  gradually  contracts  down,  and  adhesions 
form,  thus  effecting  a  cure.  The  walls  of  the  scrotum,  however,  are  usually  much 
thickened  by  a  chronic  hydrocele,  and  never  regain  their  former  thinness. 

When  the  accumulation  of  liquid  is  larger,  as  in  chronic  hydrocele  with  thick- 
ened walls,  Volhmann's  operation  is  advised.  Shave  the  scrotum  and  pubes,  and 
wash  the  parts  thoroughly  with  brush,  soap,  and  water,  and  afterward  with  mer- 
curic chloride.  The  sac  of  the  hydrocele  is  then  opened  by  an  incision  varying  in 
length  from  three  to  six  inches  or  more,  as  the  case  may  require,  upon  the  anterior 


592 


HYDROCELE 


surface  of  the  tumor.  All  bleeding  should  be  arrested  as  the  operation  progresses. 
When  the  sac  is  reached  it  should  be  incised  to  correspond  to  the  length  of  the 
incision  in  the  contracted  scrotum.  Allow  the  fluid  to  escape,  and  with  a  good- 
sized  continuous  catgut  suture  stitch  the  parietal  layer  of  the  tunica  vaginalis  to 
the  edge  of  the  wound  in  the  integument,  making  a  wound  not  unlike  a  button- 
hole. After  irrigation  with  a  1-5000  mercuric-chloride  solution  insert  a  wick  of 
gauze  in  the  upper  and  lower  portions  of  the  cavity.  A  sterilized  dressing  is  placed 
over  all,  which  need  not  be  changed  before  the  fourth  or  fifth  day,  and  often  two 
or  three  changes  will  suffice  to  effect  a  cure.  A  shorter  gauze  wick  may  be  inserted 
after  each  dressing. 

The  conditions  are  very  rare  which  call  for  ether  or  chloroform  narcosis  in 
the  performance  of  this  operation.  Even  in  cases  in  which  a  cure  cannot  be 
effected  by  the  simple  method  of  Levis  it  is  not  necessary  to  secure  any  better 
anc"esthesia  than  that  obtained  with  cocaine.  A  one-per-cent  solution  injected  into 
the  integument  of  the  scrotum  in  the  line  of  incision  will  give  perfectly  satisfactory 
ancesthesia  in  the  vast  majority  of  instances,  enabling  the  operator  to  open  the 
sac,  discharge  its  contents,  and  irrigate  and  insert  the  wick  drain  without  pain. 

Hydrocele  of  the  cord  is  much  less  frequently  met  with,  and  consists  in  the 
accumulation  of  a  fluid  in  character  similar  to  that  of  hydrocele  of  the  tunica 
vaginalis. 

Hydrocele  of  the  tunica  funiculi  (Fig.  607)  appears  as  a  roiind,  slightly  elon- 
gated cyst  or  tumor,  movable  in  all  directions  with  the  tissues  of  the  cord,  not 
communicating  below  with  the  tunica  vaginalis  or  above  with  the  peritoneal  cavity. 
It  rarely  attains  a  large  size,  although  as  much  as  three  ounces  of  fluid  may  be 
met  with  in  rare  cases. 

The  diagnosis  between  hydrocele  of  the  tunica  funiculi  and  spermatocele  in 
this  same  region  is  ex-ceedingiy  difficult,  and  cannot  be  positively  made  without 
aspiration.  Fluid  drawn  off  from  a  hydrocele  of  the  cord  is  straw-colored,  while 
that  of  a  spermatocele  is  milky-white,  and  not  unlike  the  fluid  which  is  found  in 
a  cocoanut.  Should  the  diagnosis  be  still  doubtful,  the  microscope  will  demon- 
strate the  presence  of  spermatozoa  if  the  case  is  one  of  spermatocele.  For  all 
practical  purposes  the  differentiation  is  of  no  moment,  since  the  treatment  is  the 


Fig.    607.— Hydrocele    of    the 
cord  encysted. 


Fig.  60S. — Congenital  hydro- 
cele. The  tunica  funiculi 
communicating  with  the  tu- 
nica vaginalis  testis  and  the 
peritoneal  cavity,  a,  Testis. 
(After  Linhart.) 


Fig.  609. — c,  Hydrocele  of  the 
cord  communicating  with  the 
peritoneal  cavity,  o,  Testis. 
b,  Small  effusion  into  the  tu- 
nica vaginalis.  (After  Lin- 
hart.) 


same  in  both — incision  under  the  same  antiseptic  precautions  as  given  for  Volk- 
mann's  operation,  opening  into  the  sac,  irrigating  with  mercuric-chloride  solution, . 
packing  with  sterile  gauze.     Careful  asepsis  should  be  carried  out  in  order  to  pre- 
vent suppuration,  for  the  inflammation  which  can  be  secured  by  cleanliness  will 
obliterate  the  sac  in  much  less  time  than  that  which  occurs  with  pus  formation. 

Hydrocele  may  sometimes  be  congenital,  fluid  descending  from  the  peritoneal 
cavity  and   along  the  cord  and  extending  into  the  tunica  vaginalis    (Fig.   608). 


HYDROCELE 


593 


Hydrocele  of  this  variety,  however,  is  rarely  met  with,  and  does  not  require  treat- 
ment unless  it  persists.     It  is  occasionally  met  with  in  very  young  infants,  and 


(After  Koclier.) 


Fig.  611. — Bilocular  hydrocele.  T  c,  Parietal 
layer  of  tunica.  S,  Spermatic  cord.  N  h, 
Epididymis.  H,  Testis.  D,  Cavity  of  diver- 
ticulum. T  V,  Cavity  of  the  tunica  vaginalis 
proprius.  Z  z,  Inflammatory  new  formation 
between  the  visceral  and  parietal  layers. 
(After  Kocher.) 


becomes  separated  from  the  peritoneal   cavity  by  closure   of  the  tunica  funiculi 
in  the  inguinal  canal.     Hydrocele  in  children,  when  not  congenital,  is  not  infre- 


FiG.  612. — Double  hydrocele  of  the  tunica  vagina- 
lis testis.  (From  a  patient  operated  upon  at 
Mount  Sinai  Hosi^ital.) 


Fig.  613. — Varicosities  of  the  spermatic  plexus 
of  veins,  with  atrophy  of  the  testicle.  (Af- 
ter Kocher.) 


594 


VARICOCELE 


quent,  and  may  often  be  cured  by  simple,  clean  evacuation  of  the  fluid  with  a 
hypodermic  apparatus  without  injection.  It  should  be  thus  treated  for  one  or 
two  or  three  times,  after  which,  should  the  fluid  re-form,  from  one  to  three  minims 
of  pure  carbolic  acid  should  be  thrown  in  after  another  aspiration. 

Ya7-icocele. — Varicosities  of  the  veins  of  the  spermatic  plexus  are  not  uncom- 
mon. Varicocele  is  chiefly  caused  by  gravity  and  the  mechanical  interference  with 
the  return  of  blood  through  the  spermatic  veins.  It  occurs  with  greater  frequency 
on  the  left  side,  where  the  vessels  are  pressed  upon  by  the  sigmoid  flexure  of  the 
colon  with  its  almost  constant  weight  of  fecal  matter.  In  addition  to  this,  the 
greater  length  of  the  left  spermatic  vein,  which  enters  the  renal  vein  at  a  right 
angle  to  its  axis,  and  is  poorly  protected  by  valves,  are  causes  which  serve  to  pro- 
duce varicosities  upon  this  side  more  frequently  than  in  the  right  plexus.  Any 
occupation  which  necessitates  the  erect  posture  is  apt  to  add  to  the  susceptibility 
of  this  disease.  Hereditary  tendencies  must  be  considered  in  its  setiology,  for 
frequently  members  of  a  family  through  several  generations  will  be  afEeeted. 


Fig.   613a. — Varicocele  of  extreme  degree.     Veins  unusually  large  and  distinct.     Duration,  fourteen 
years.     Patient  aged  twenty-nine  years.      (Foote.) 


The  earlier  symptoms  are  a  feeling  of  heaviness  or  dragging  down  on  the  side 
affected,  with  the  appearance  of  a  small  swelling  in  the  line  of  the  cord.  Pain 
is  variable,  and  is  sometimes  referred  to  the  cord  or  to  the  inguinal  region  or 
down  the  leg.  The  testicle  hangs  lower  than  natural,  and  along  the  cord  can  be 
felt  a  network  of  turgid  veins  extending  from  the  epididymis  toward  the  external 
ring.  To  the  touch  they  seem  not  unlike  a  knot  of  earthworms.  The  swelling' 
is  apt  to  be  largest  at  the  lower  extremity  (Fig.  613). 

The  diagnosis  is  not  difficult.  The  swelling  of  inguinal  hernia  is  spherical, 
and,  when  composed  of  intestine,  it  is  resonant  on  percussion.  If  the  hernia  is 
reducible,  and  is  returned  into  the  cavity  of  the  abdomen  with  the  patient  in  the 
recumbent  posture,  and  if  the  index-finger  is  carried  into  the  internal  ring  and 


VARICOCELE 


595 


held  there  while  the  patient  is  made  to  stand  erect,  the  veins  will  again  refill 
and  demonstrate  the  varicocele,  while  the  hernia  will  be  prevented  J^rom  descend- 
ing. Hffimatoma,  or  hydrocele  of  the  cord,  can  be  recognized  by  aspiration  with 
the  hypodermic  syringe. 

Treatment. — In  general,  a  well-adjnsted  suspensory  apparatus  constantly  worn 
when  in  the  erect  position  will  obviate  the  necessity  for  an  operation.  A  double 
elastic  apparatus  is  advisable.  When  the  annoyance  of  the  suspensory  bag  is  great, 
or  if  it  is  ineffectual,  operative  interference  is  demanded.  There  is  but  one  method 
for  the  radical  cure  of  varicocele  that  is  advisable.     It  is  as  follows : 

Shave  and  thoroughly  cleanse  with  brush,  soap,  and  water  the  entire  field  of 
operation  and  contiguous  surfaces.  An  incision  is  made  that  should  extend  from 
one  inch  above  the  external  abdominal  ring,  down  along  the  spermatic  cord, 
through  the  tissues  of  the  scrotum  to  the  upper  margin  of  the  epididymis.  Care- 
ful dissection  will  expose  the  entire  cord  without  wounding  any  veins  which  enter 
into  its  composition.  The  vas  deferens  can  be  easily  recognized,  not  only  by  the 
sense  of  touch,  since  it  feels  like  a  round  leather  shoestring  when  pressed  between 
the  fingers,  but  by  the  eye.  This  should  be  carefully  separated  from  all  the 
remaining  tissues  of  the  cord,  together  with  one  or  two  veins,  the  artery  of  the  vas 
deferens  and  the  nerve,  which  are  in  one  sheath,  from  the  level  of  the  epididpnis 
to  the  external  ring.  A  good-sized  catgut  ligature — usually  the  largest  size — is 
now  tied  around  the  part  to  be  excised  near  the  epididymis,  and  a  second  ligature 
at  the  external  ring.  The  intervening  portion  is  cut  through  with  scissors  and 
removed.  By  leaving  the  ends  of  the  two  ligatures  fairly  long,  these  can  be  tied 
together,  bringing  the  testicle  up  in  proper  position  and  holding  it  temporarily 
until  adhesions  occur.  The  wound  should  be  carefully  dried,  closed,  and  sealed 
with  sterile  collodion.  It  is  a  wise  precaution  to  insert  a  twist  of  tv/o  or  three 
strands  of  catgut  in  the  lower  angle  of  the  wound,  in  order  to  give  exit  to  the 
serous  transudate  which  nearly  always  follows  this  operation.  The  collodion  can 
be  lifted  at  this  point  to  permit  the  escape  of  serum  or  blood. 

In  the  majority  of  cases  the  scrotum  will  be  found  so  elongated  that  amputa- 
tion of  the  redundant  portion  is  essential  to  comfort  and  cleanliness.  In  per- 
forming this  operation  the  testicles  should  be  pushed  well  up  toward  the  external 
ring  and  a  little  more  of  the  scrotum  amputated  than  may  seem  necessary;  the 
tissues  are  retracted  to  a  much  greater  degree  under  the  ansesthetic  than  normal. 
The  operation  is  much  facilitated  by  using  the  scrotal  clamp  (Fig.  614),  which, 
if  properly  adjusted,  will  hold  the  tissues  firmly  while  the  amputation  is  being 
made,  and  the  wound  closed  with  strong  catgut  sutures,  thus  preventing  all  hffiui- 
orrhage  and  the  necessity  of  applying  any  ligatures  in  the  line  of  incision.     If 


scrotal  clainj^. 


this  instrument  cannot  be  obtained.  Smith's  hemorrhoidal  cautery  clamp  may 
be  used,  applying  the  clamp  over  a  portion  of  the  line  of  amputation,  making  the 
section  about  one  fourth  of  an  inch  in  front  of  it,  and  inserting  and  tying  the 
sutures  before  further  section  is  made.  If  no  apparatus  can  be  obtained,  the  fingers 
of  an  assistant  will  prevent  hajmorrhage  while  the  operation  proceeds.  This  wound 
should  be  sealed  at  once  with  collodion. 

Cocaine    infiltration    should   give    a   perfectly    satisfactory   anggsthesia    in   this 
operation. 


596  THE   TESTICLE 

The  va^  deferens  is  more  or  less  involved  in  all  inflammatory  jjrocesses  which 
occur  in  the  epididymis.  It  is  also  subject  to  invasion  by  inflammation  from  the 
urethra  and  prostate.  Tuberculosis  of  this  vessel  may  follow  tuberculosis  of 
the  testes  and  epididymis. 

In  chronic  vesiculitis  benefit  may  be  derived  by  the  stimulation  which  results 
from  digital  pressure  or  massage.  This  is  done  by  carrying  the  index-finger  into 
the  rectum  until  these  organs  are  felt,  and  exercising  gentle,  steadj'  pressure 
with  the  tip  of  the  finger  applied  from  behind  forward. 

Epididymis. — Neoplasms  of  the  sheath  of  the  spermatic  cord  are  rare.  Kocher 
mentions  isolated  cases  of  lipoma,  fibroma,  or  myxofibroma  and  sarcoma. 

Epididj'mitis  results  occasionally  from  direct  violence,  but  is  chiefly  due  to 
urethritis  and  the  extension  of  the  inflammatory  process  along  the  vas  deferens. 
Metastatic  or  "  sympathetic "  inflammation  of  this  organ  is  very  rare.  It  may 
be  acute  or  chronic.  The  inflammatory  process  may  be  conflned  to  the  epididymis 
or  invade  the  testicle.  Acute  epididymitis  always  involves  the  tunica  vaginalis 
(with  which  it  is  in  contact),  and  very  frequently  the  testicle.  Siiecific  urethritis 
stands  first  in  order  in  the  causation  of  epididymitis.  The  introduction  of  a 
sound  or  catheter,  the  lodgment  of  a  calculus  in  the  urethra  or  prostate,  stricture, 
cystitis,  and  prostatitis  may  also  cause  this  disease. 

Tlae  symptoms  of  acute  ejjididymitis  are  a  sense  of  uneasiness  or  jDain,  varying 
in  intensity  in  the  organ  affected,  or  in  the  cord  or  groin.  It  is  increased  by 
pressitre,  when  the  erect  posture  is  assumed,  or  in  walking. 

In  severe  cases  a  chill  or  rigors  occur,  followed  by  a  marked  rise  in  tempera- 
ture. Upon  inspection  there  will  be  more  or  less  induration  along  the  posterior 
border  of  the  testicle,  with  heat,  redness,  and  tension.  The  testicle  is  more  or  less 
enlarged,  and  very  frequentlj'  there  is  a  serous  transudation  into  the  cavity  of  the 
tunica  vaginalis  testis.   • 

The  pathological  changes  consist  chiefly  of  hyperajmia  and  infiltration  of  the 
connective-tissue  framework  with  embryonic  cells.  The  epithelial  lining  membrane 
is  also  thickened  and  injected. 

The  diagnosis  depends  upon  the  symptoms  above  given.  The  prognosis  is 
usually  favorable.  One  attack,  however,  predisposes  to  another.  In  some  in- 
stances occlusion  of  the  efferent  apparatus  results  from  contraction  of  the  products 
of  inflammation,  and  sterility  follows.  Spermatic  fistula  may  result.  As  before 
stated,  the  prognosis  is  more  serious  when  the  globus  minor  is  involved. 

The  treatment  consists  in  the  administration  of  saline  laxatives  in  order  to 
empty  the  alimentary  canal.  The  patient  should  be  placed  upon  his  back,  and 
the  infiamed  organ  supported  by  either  a  three-cornered  pillow  between  the  thighs, 
or  a  towel  pinned  around  both  thighs  just  below  the  base  of  the  scrotum.  Upon 
this  a  small  bladder  filled  witli  crushed  ice  may  be  placed,  and  the  inflamed  organ 
allowed  to  rest  upon  it.  If  cold  is  not  gratefid,  warm  cloths  or  a  poultice  may 
be  substituted.  The  application  of  from  three  to  six  leeches  will  at  times  relieve 
the  local  congestion. 

Usually  rest  in  bed  will  alone  suffice  to  effect  a  cure.  In  some  instances  oper- 
ative interference  is  indicated. 

The   Testicle 

The  Testicle. — Wounds  of  this  organ  do  not  demand  especial  consideration. 
Hernia  of  the  tubules  not  infrequently  occurs  from  incision  or  puncture  of  the 
tunica  albuginea.  Eeduction  is  practically  impossible.  The  protruded  portion 
should  be  tied  off  with  a  catgut  ligature,  the  excess  of  substance  beyond  the  thread 
cut  off,  and  the  organ  returned  to  the  normal  position. 

Inflammation  of  tire  testis  (orchitis)  may  result  from  direct  violence,  from  the 
exteirsion  of  an  epididymitis,  or  from  metastatis.  Orchitis  is  met  witli  as  a 
symptom  of  "mumps,"  but  the  relation  between  these  two  processes  is  not 
understood. 

The  symptoms  are  enlargement  of  the  organ,  with  pain  usually  intense  in  the 
acute  variety.     The  swelling  is  slow  on  account  of  the  great  resistance  offered  by 


THE   TESTICLE  597 

the  tunica  albuginea.  The  skin  over  the  organ  is  tense  and  reddened,  and  at  times 
cedematous,  especially  when  an  epididjTnitis  precedes  the  infiammator}'  process 
in  the  testicle. 

In  severe  cases  gangrene  may  ensue,  and  the  tunica  Taginalis  and  scrotal  walls 
may  become  involved.  In  mild  cases  the  pathological  changes  are  chiefl}'  hypera;- 
mia  and  the  formation  of  a  limited  amount  of  embryonic  tissue  along  the  blood- 
vessels and  in  the  connective-tissue  septa  of  this  organ.  In  the  severer  forms  this 
process  is  greatly  exaggerated,  and  as  a  result  of  the  extensive  hyperplasia  the 
circulation  is  arrested,  and  death  of  the  tubular  structure  ensues.  Or,  if  gangrene 
does  not  occur,  atrophy  of  the  excretory  apparatus  follows  as  a  result  of  contrac- 
tion of  the  products  of  inflammation.  In  some  instances  the  swelling  subsides, 
leaving  no  marked  changes  in  the  organ. 

Prognosis. — Mild  cases,  especially  in  the  forms  occurring  with  urethral  epidid- 
ymitis, generally  terminate  in  one  or  t'^'o  weeks  in  recovery  and  restoration  of 
the  organ  to  its  normal  condition.  In  cases  where  the  symptoms  are  severe  from 
the  start,  the  prognosis  is  grave  unless  early  relief  is  afforded,  and  even  then  it 
is  not  always  favorable. 

Treatment. — Best  in  the  dorsal  decubitus  should  be  insisted  upon  in  even  the 
mildest  cases,  for  not  infrequently,  dangerous  orchitis  is  provoked  by  neglect  of 
this  precaution. 

The  position  of  the  testicle  should  be  elevated,  as  in  epididj^mitis.  The  local 
application  of  cold  is  grateful  and  advantageous  in  most  cases.  The  organ  is, 
however,  so  sensitive  that  no  pressure  is  tolerated.  This  can  be  obviated  by  making 
a  ring  of  cloths  -nTapped  around  a  small  hoop,  leaving  a  lumen  large  enough  to 
include  the  scrotum  and  penis.  The  ice-bag  is  laid  upon  this  ring,  which  prevents 
any  pressure  upon  the  testicle. 

When  the  effusion  is  rapid,  causing  dangerous  tension  of  the  fibrous  capsitle, 
surgical  interference  is  imperative. 

The  operation  consists  in  seizing  the  organ  with  the  left  hand,  so  as  to  render 
it  steady  and  the  skin  tense,  puncturing  the  scrotum  and  parietal  layer  of  the 
tunica  vaginalis  testis,  and  thus  subcutaneoush'  making  a  series  of  incisions  through 
the  tunica  albuginea  on  its  anterior  and  antero-lateral  aspects.  The  incisions 
should  be  about  half  an  inch  in  length,  and  are  much  preferable  to  simple 
puncture. 

The  danger  of  hernia  testis  does  not  contra-indicate  this  procedure. 

Chronic  orchitis,  not  due  to  syphilis,  is  comparatively  rare.  When  it  occurs, 
it  usually  follows  an  acute  inflammation.  The  pathological  change  consists  in  a 
thickening  of  the  tunica  albuginea  and  of  the  connective-tissue  septa.  Embryonic 
cells,  collected  in  groups  or  nests,  in  various  stages  of  development,  are  crowded 
along  and  around  the  blood-vessels  and  seminiferous  tubules,  as  well  as  scattered 
about  in  the  intertubular  spaces.  As  the  process  continues,  the  tubules  disappear 
umler  the  pressure  of  the  new  products  of  inflammation.  In  a  certain  proportion 
of  eases  cysts  form  in  the  following  manner:  The  peripheral  cells  of  one  or  more 
foci  of  the  embryonic  tissue  organize  into  connective  tissue  and  aid  in  forming 
the  investing  capsule.  The  cells  within  this  new  capsitle  xmdergo  granidar  meta- 
morphosis, and  later  liquefaction,  by  absorption  of  fluid  from  the  surrounding 
vessels.  In  other  cases  foci  of  suppuration  (midtiple  abscess  of  the  testicle)  may 
remain  from  an  acute  inflammation  and  be  present  in  chronic  orchitis  long  after 
the  acute  symptoms  have  subsided.  The  contents  of  these  foci  may  also  undergo 
caseous  degeneration. 

The  symptoms  of  chronic  orchitis  are  those  of  progressive  enlargement  of  this 
organ.  In  some  instances  pain  is  wanting,  in  others  it  is  present,  though  less 
intense  than  in  the  acute  form,  while  in  a  third  category  may  be  classed  cases  of 
chronic  orchitis  with  intercurrent  attacks  of  acute  inflammation  and  the  accom- 
panying exacerbations  of  pain.  The  organ  varies  in  size  from  two  to  four  or  five 
inches  in  its  greatest  diameter.  Much  annoyance  may  be  occasioned  by  the  drag- 
ging upon  the  cord. 

The  diagnosis  is  between  hydrocele  of  the  tunica  vaginalis,  inflammation  of 
the  walls  of  this  cavitv',  with  exudation  and  thickening  and  adhesion  to  the  testicle, 


598  THE   TESTICLE 

syphilitic  orchitis,  and  tuberculous  testis.  Hydrocele  is  easily  excluded  by  fluc- 
tuation, translucency,  and  aspiration.  In  periorchitis  with  exudation  and  adhe- 
sions, differentiation  will  at  times  be  difficult.  The  obliteration  of  the  cavity  of 
the  tunica  vaginalis  renders  the  superficial  tissues  less  freely  movable  upon  the 
body  of  the  testis.  In  orchitis  the  surface  of  the  enlargement  is  smooth,  spherical, 
and  of  like  consistence  at  all  points;  often  in  periorchitis  ridges  of  new  tissue 
can  be  made  out;  there  are  soft  spots  or  depressions  which  can  be  recognized  by 
careful  palpation. 

If  syphilitic  orchitis  is  suspected  (even  if  the  history  of  this  disease  is  denied), 
it  will  be  advisable  to  administer  the  protoiodide  of  mercury  and  the  iodide  of 
potassium  for  several  weeks.  The  marked  diminution  of  the  tumor  will  be  con- 
firmatory of  the  suspicion  of  the  syphilitic  dyscrasia.  The  extraordinary  weight 
of  a  syphilitic  testicle  should  be  borne  in  mind. 

Tuberculosis  testis  is  usually  preceded  by  the  deposit  of  tuberculous  matter  in 
the  epididymis.  Pain  in  this  affection,  when  uncomplicated  by  pyogenic  infection, 
is  insignificant  and  entirely  disproportionate  to  the  rapidity  of  the  infiltration  and 
enlargement.  Moreover,  orchitis  and  epididymitis  may  usually  be  traced  to  some 
direct  and  exciting  cause  which  is  absent  in  tubercular  disease. 

The  indications  in  treatment  are,  first  of  all,  to  remove  every  cause  of  irrita- 
tion, to  keep  up  the  tone  of  the  system  by  judicious  feeding  and  medication,  and 
to  support  the  heavy  organ  by  suspension.  When  these  measures  fail  to  arrest 
the  disease,  or  when  the  pain  becomes  so  great  that  the  patient's  comfort  is  inter- 
fered with,  or  when  the  disintegration  of  the  organ  is  threatened,  castration  may 
be  entertained.  Before  carrying  out  such  an  extreme  measure,  the  precaution 
should  be  taken  to  explore  the  organ  through  an  incision  in  the  scrotum,  in  order 
to  determine  its  exact  condition  before  removing  it. 

Tuberculosis  of  the  Testicle  and  JEpididymis. — True  miliary  tuberculosis  of  the 
testicle  and  epididymis  is  comparatively  rare.  Many  cases  which  have  been  re- 
corded as  tiiberculosis  must,  upon  analysis,  be  classed  with  a  non-tubercular  inflam- 
mation, the  embryonic  tissue  of  which  has  undergone  caseous  degeneration. 

Primary  tubercular  disease  of  the  testicle  is  the  exception.  The  epididymis 
is  usually  first  invaded,  and  from  this  point  the  new  tissue  spreads  into  the  testicle, 
and  not  infrequently  along  the  vas  deferens  to  the  seminal  vesicles,  as  well  as 
to  the  tunica  funiculi  and  tunica  vaginalis  testis. 

AYhile  it  may  be  slow  in  some  instances,  as  a  rule  the  invasion  is  rapid,  occup)''- 
ing  from  two  to  eight  weeks  in  a  general  infiltration  of  both  organs.  The  symp- 
toms are,  upon  the  whole,  obscure.  One  point  of  great  diagnostic  value  is  that 
the  pain  is  entirely  disproportionate  to  the  rapidity  and  extent  of  the  tumefaction. 
In  simple  orchitis  and  epididymitis,  pain  is  extreme  and  pressure  unbearable.  In 
tubercular  orchitis  pain  is,  as  a  rule,  slight,  and  may  not  be  present  at  all.  In  a 
certain  proportion  of  cases  there  will  be  sudden  and  recurring  exacerbations  of 
pain  indicating  a  circumscribed  acute  orchitis  the  result  of  irritation  from  the 
presence  of  the  cell  elements  of  the  tubercular  process  or  a  mixed  (pyogenic) 
infection.  Ulceration  and  the  formation  of  fistulee  occur  in  a  certain  proportion 
of  cases. 

In  simple  orchitis  and  epididj^mitis  the  cord  is  not  involved,  while  not  infre- 
quently in  tuberculosis  the  deposit  rapidly  travels  along  the  vas  deferens.  Grasped 
between  the  fingers,  the  tubercular  organ  is  felt  to  be  hard,  and  its  surface  uneven 
and  nodular. 

■  The  initial  morbid  change  is  the  deposit  around  the  seminiferous  tubes  of 
clusters  or  nests  of  lymphoid  cells.  Within  the  tubes  the  endothelia  are  thickened 
and  are  undergoing  granular  or  caseous  metamorphosis.  Later,  the  connective- 
tissue  septa  become  infiltrated  with  the  new  cells.  The  process  ends  in  compression 
and  destruction  more  or  less  complete  of  the  tubules.  The  centers  of  these  clusters 
of  cells  farthest  removed  from  the  vascular  network  undergo  granular  or  caseous 
metamorphosis,  forming  at  times  cystlike  caverns,  or  at  other  times  abscesses  and 
fistulse. 

Treatment. — The  prognosis  of  tubercular  disease  of  these  organs  is  so  grave 
that  when  an  earlj'  diagnosis  can  be  made  out,  extirpation  of  the  diseased  tissues 


THE   TESTICLE  599 

should  be  considered.  If  only  one  side  is  involved,  and  the  other  organ  is  fully- 
developed,  there  should  be  no  hesitation  in  advising  the  operation  of  castration. 

When  the  diagnosis  is  doubtful,  it  will  be  wise  to  keep  the  patient  under  con- 
stant observation,  with  especial  regard  to  the  advance  of  the  disease  along  the 
cord,  and  when  this  is  evident,  and  when  there  is  no  positive  evidence  of  tubercular 
dejjosits  elsewhere,  extirpation  is  indicated  in  order  to  jirevent  invasion  of  the  pros- 
tate and  general  dissemination.  When  both  organs  are  involved,  the  question  of 
complete  castration  may  be  submitted  to  the  patient. 

Enchondroma  of  the  testicle  is  not  altogether  infrequent.  It  occurs  most  often 
after  injury.  While  it  is  prone  to  originate  in  this  organ,  it  may  spread  from  the 
epididymis  to  the  testicle.  The  volume  of  the  organ  varies,  at  times  reaching  a 
large  size.  Enchondroma  testis,  as  with  almost  all  forms  of  neoplasm  seated  in 
this  structure,  is  apt  to  undergo  cystic  degeneration. 

The  diagnosis  must  be  based  upon  the  hard,  elastic  feel  peculiar  to  this  form 
of  tumor. 

The  treatment  is  either  expectant  or  operative,  as  circumstances  may  demand. 
Castration  is  indicated  when  the  disease  is  unilateral,  and  when  the  size  of  the 
tumor  is  such  that  the  function  of  the  opposite  organ  is  threatened.  The  mixed 
treatment  should  be  thoroughly  tested  in  all  instances  where  the  diagnosis  is 
obscure. 

Adenoma  testis  occurs  chiefly  from  the  twentieth  to  the  fortieth  year  of  life. 
It  has  so  far  not  been  observed  during  childhood. 

The  development  of  the  tumor  is  usually  rapid,  attaining  a  diameter  of  three 
or  four  inches  or  more.  Only  one  organ  is  usually  affected.  Pain  is  not  a  promi- 
nent symptom  in  the  earlier  'history  of  this  neoplasm,  but,  after  the  growth  attains 
a  sufiicient  bulk,  it  causes  more  or  less  pain  by  pressure  and  weight.  To  the  touch 
it  is  soft  and  compressible.  The  formation  of  cysts  in  various  portions  of  the 
neoplasm  is  frequent   (cysto-adenoma). 

ITnder  the  microscope  the  epithelia  of  the  seminiferous  tubules  are  seen  to  be 
swollen  while  their  caliber  is  more  or  less  completely  occluded  with  the  round  cells 
of  the  new  (adenoid)  tissue. 

The  prognosis  is  not  favorable,  and  the  diagnosis  difficult.  Since  the  function 
of  the  organ  is  wholly  impaired,  and  since  the  rapid  development  of  the  tumor 
is  of  itself  an  indication  of  the  gravity  of  the  lesion,  the  matter  of  exact  recog- 
nition of  adenoma  is  not  important.  In  all  of  these  rapid  and  threatening  neo- 
plasms, especiallj^  when  a  single  testicle  or  epididymis  is  involved,  the  safest  course 
is  in  early  and  prompt  excision. 

Carcinoma. — Both  scirrJius  and  medullary  cancer  may  develop  primarily  in 
the  testicle  or  epididymis.  The  encephaloid  variety  is  most  frequently  encountered. 
The  microscopical  characters  of  these  difl'erent  varieties  of  cancer  will  be  given  in 
the  chapter  on  tumors. 

Carcinoma  of  the  testis  is  apt  to  occur  about  the  age  of  puberty,  although  it 
may  be  met  with  later  in  life.  One  organ  is  affected,  as  a  rule.  It  is  more  apt 
to  "begin  in  the  testicle  than  in  the  epididpnis.  In  the  early  stages  of  the  devel- 
opment cancer  of  the  testes  is  not  painful,  but  as  the  disease  advances  the  suffering 
may  be  intense.  Early  removal  offers  the  only  hope  of  cure,  and  this,  unfortu- 
nately, is  not  great. 

Sarcoma  testis  occurs  at  all  ages,  but  is  chiefly  confined  to  childhood  and  early 
manhood.  Following  the  general  law  of  sarcomata,  that  of  the  testicle  is  rapid 
in  growth,  attaining  at  times  an  enormous  size.  This  is  one  of  the  chief  diag- 
nostic points  of  this  tumor,  which  is  hard,  usually  pyriform  in  shape,  and  of 
comparatively  smooth  contour.     Castration  offers  the  only  hope  of  relief. 

It  will  be  seen  from  the  foregoing  that  accurate  diagnosis  of  the  various  neo- 
plasms which  develop  in  the  testicle  is  difficult  and  often  impossible.  Almost  all 
of  these  morbid  processes  lead  to  destruction  of  the  organ  and  loss  of  function, 
and  immediately  or  remotely  threaten  tlie  life  of  the  individual. 

Thus  tuberculosis,  adenoma,  carcinoma,  and  sarcoma  may  be  classed  as  malig- 
nant. Enchondroma,  although  not  intrinsically  malignant,  leads  to  loss  of  func- 
tion, and  in  this  particular  justifies   ojjerative  interference.     The  same  applies 


goo  THE  TESTICLE 

with  o-reater  force  to  cj'stic  degeneration  of  this  organ,  since  cysts  often  develop 
in  malignant  neoplasms  of  the  testicle.  In  view  of  these  facts,  when  only  a  single 
organ  is  involved,  it  will  be  advisable  in  the  early  history  of  any  neoplasm  of  this 
organ  to  consider  the  propriety  of  castration. 

The  operation  is  thus  performed:  Shave  the  scrotum  and  pubes,  and  make  an 
incision  extending  from  the  external  abdominal  ring  along  the  anterior  surface 
of  the  cord  and  testicle  to  the  base  of  the  scrotum.  When  the  morbid  process 
involves  the  scrotal  tissues,  and  even  when  there  is  a  suspicion  of  involvement,  the 
primary  incision  should  be  carried  well  away  from  the  suspected  tissue  into  the 
healthy  structiires. 

Two  points  of  importance  are  suggested  in  the  removal  of  this  organ.  The 
first  is  to  make  an  incision  into  the  mass  in  order  to  clear  up  the  diagnosis;  the 
second  is  to  secure  the  vessels  by  the  ligature  applied  near  the  external  ring,  and 
thus  prevent  the  danger  of  forcing  septic  or  metatastic  matter  in  the  lymph  channels 
or  vessels  leading  toward  the  center.  The  cord  should  be  exposed  at  the  ring,  the 
vas  deferens  isolated,  and  a  large,  double  catgut  ligature  thrown  around  so  as  to 
include  the  entire  cord  except  the  vas  deferens.  This  is  twisted  around  the  cord 
while  the  exploratory  incision  is  being  made,  and,  if  the  diagnosis  is  confirmed, 
the  catgut  is  tied  and  the  cord  divided  between  the  two  ligatures.  The  diseased 
organ  is  then  dissected  out,  the  haemorrhage  arrested,  drainage  secured,  and  the 
wound  closed  with  catgut  sutures.  A  single  dressing  will  usually  suffice.  When 
the  vas  deferens  is  divided,  the  accompanying  artery  should  be  separately  tied. 

Malposition.- — One  or  both  of  these  organs  may  be  absent  from  the  normal 
position  in  the  scrotal  sac.  The  descent  from  the  abdominal  cavity  may  be  pre- 
vented by  narrowing  or  closure  of  the  inguinal  rings,  or  the  inner  ring  may  be 
passed,  the  testicle  being  arrested  at  the  outer  opening,  and  thus  imprisoned  in  the 
canal ;  or,  passing  both-  rings,  it  may  lodge  beneath  the  skin  near  the  pubic  crest, 
or  in  the  perinseum  or  groin.  Occasionally  the  testicle  remains  entirely  within 
the  abdominal  cavity.  Another  rare  form  of  malposition  is  when  the  organ  is 
turned  obliquely  or  crosswise  in  the  scrotum. 

Misplaced  testicle  does  not  usually  give  rise  to  great  inconvenience  until  the 
approach  of  puberty,  when  its  normal  development  is  interfered  with  by  com- 
pression. If  it  is  lodged  in  the  inguinal  canal,  where  it  is  acted  uj)on  by  muscular 
contraction,  it  may  cause  pain  at  an  earlier  period.  The  descent  of  a  hernia  upon 
a  testicle  thus  imjwisoned  gives  rise  to  considerable  annoyance.  An  imprisoned 
testicle  is  occasionally  the  seat  of  a  neoplasm.  The  symptoms  are  those  of  pain, 
neuralgic  in  character  and  the  diagnosis  must  depend  upon  the  absence  of  the 
organ  from  its  normal  place  and  its  recognition  in  the  position  of  the  abnormal 
swelling.  The  author  removed  in  one  patient,  two,  and  in  another  one  greatly 
enlarged  intra-abdominal  testicle  in  which  sarcoma  had  developed.  Both  recov- 
ered, and  there  was  no  symptom  of  recurrence  after  two  years. 

When  one  or  both  organs  are  imprisoned  in  the  inguinal  canal  or  more  deeply 
situated,  an  effort  should  he  made  to  bring  them  into  the  scrotum.  An  incision 
of  sufficient  length  should  be  made  over  the  inguinal  canal,  a  little  lower  down 
than  that  for  oblique  inguinal  hernia.  The  aponeurosis  of  the  external  oblique 
should  be  divided  from  the  arch  of  the  anterior  ring  upward  in  the  direction  of 
its  fibers,  far  enough  to  thoroughly  expose  the  canal.  In  this  will  usually  be 
found  the  imprisoned  testicle  and  the  cord.  By  careful  manipulation  the  cord 
and  testicle  should  be  loosened.  Care  should  be  taken  to  preserve  the  gubernaculum 
testis,  which  is  finally  divided  as  far  as  possible  from  the  organ,  namely,  near  the 
pillars  of  the  external  ring.^  When  this  is  done,  the  testicle  can  usually  be  brought 
down  into  the  scrotum.  The  scrotal  pouch  should  be  enlarged  and  an  incision 
from  the  outside  made  into  its  cavity.  Through  this  incision,  a  dressing  forceps, 
carrying  a  long  strand  of  catgut,  is  pushed  upward  into  the  open  wound,  where - 
it  is  temporarily  fastened  to  the  gubernaculum  and  then  brought  back  through 
the  opening  in  the  scrotum.  This  loop  aids  in  the  downward  traction  of  the 
organ,  and  if  necessary  may  be  used  as  a  suture  to  hold  it  in  position.     When 

■  W.  M.  Brickner,  "Amer.  Jour,  of  Surgery,"  March,  1906. 


THE  TESTICLE  601 

the  cord  is  so  short  that  the  testicle-  cannot  be  made  to  descend  into  the  scrotum, 
it  should  be  brought  outside  the  external  ring. 

The  inguinal  canal  is  now  closed  after  tlie  method  of  Bassini,  as  in  hernia. 
In  certain  eases  it  may  be  advisable  to  operate  upon  only  one  organ  at  a  time, 
rather  than  subject  the  child  to  a  long  procedure. 

When  both  organs  are  abnormally  situated,  one  or  both  should  be  brought  out 
of  the  canal  and-  carried,  if  possible,  into  the  scrotum. 

Traumatic  dislocation  of  the  testicle  may  also  occur.  Dr.  Eamon  Guiteras  ^ 
reported  a  dislocation  of  this  organ  into  the  loose  tissues  between  the  integument 
of  the  penis  and  the  body  of  this  organ.  A  successful  reduction  was  made  by  a 
long  incision  which  exposed  the  testicle,  and  was  continued  until  the  contracted 
tunica  vaginalis  testis  was  opened. 

1  "Medical  Record,"  January  4,  1896. 


CHAPTER   XXXI 

THE    GENITO-UKIXAEY    ORGANS    IN    FEMALES 

The  examination  of  the  genito-urinai\Y  organs  sliould  be  preceded  by  tlior- 
oughly  emptying  the  bowels  by  purgation  or  colon  irrigation,  and  by  a  warm 
sitz-bath,  followed  by  irrigation  of  the  vagina  with  a  1-3000  mercuric-chloride 
solution.  T]ie  vaginal  douche  should  be  given  wdth  the  patient  upon  the  back, 
the  thighs  flexed  and  the  pelvis  resting  upon  a  Kelly  pad  or  bedpan,  with  tlie 
fountain  syringe  elevated  sufficiently  to  give  considerable  force  to  the  irrigating 
fluid.  This  should  be  as  hot  as  the  patient  can  comfortably  endure,  and  should, 
by  using  a  long  tube,  be  carried  directly  into  the  deeper  portions  of  the  vagina. 
The  examiner  should  wear  sterile  rubber  gloves,  or  cots  of  sufficient  length  to 
entirely  cover  the  fingers.  It  is  always  advisable  to  have  a  1-1000  mercuric- 
chloride  solution  on  hand  for  immediate  disinfection  in  case  of  accidental  contact 
with  infectious  material. 

An  anaesthetic  may  be  required  in  rare  instances  where  pain  is  severe  or  in 
very  young  subjects  whose  sensibilities  may  preclude  an  examination  without 
narcosis. 

The  momentary  inhalation  of  nitrous-oxide  gas  will  always  give  a  perfectly 
satisfactory  anaesthesia  for  a  brief  examination. 

The  patient  should  be  thoroughly  covered  with  a  sheet,  and  placed  in  either 
the  dorsal  or  lateral  (Sims)  position.  For  the  former,  the  sacrum  rests  upon  the 
edge  of  the  table,  the  legs  are  flexed  on  the  thighs,  and  these  are  separated  and 
flexed  upon  the  abdomen,  while  the  knees  are  steadied  by  an  assistant.  The  finger, 
properly  lubricated,  is  introduced  at  the  loivcr  angle  of  the  vulva,  and  should  be 
carried  along  the  floor  of  the  vagina.  Contact  with  the  sensitive  surfaces  of  the 
upper  commissure,  nymphse.  or  vaginal  roof  should,  when  possible,  be  avoided. 

It  is  important  to  note  the  direction  and  size  of  the  cervix  uteri,  whether  any 
erosions  or  lacerations  are  present,  and  whether  tenderness  is  evident  from  pressure 
on  either  side  over  the  known  locations  of  the  tubes  and  ovaries,  or  in  the  median 
line,  where  the  urethra  and  bladder  are  located.  With  the  right  hand  on  the 
abdomen  just  ahove  the  symphysis,  by  making  steady  downward  pressure  with  the 
fingers,  and  counter-pressure  with  the  index-finger  in  the  vagina,  the  body  of 
the  uterus  may  be  palpated,  and  its  size  and  the  direction  of  its  long  axis  deter- 
mined. If  it  cannot  .be  felt  by  this  effort,  it  may  be  inferred  that  the  fundus  is 
in  the  hollow  of  the  sacrum,  with  retroversion  or  reti'oflexion.  The  insertion  of 
an  instrument  Avith  proper  curve  into  the  rectum  will  enable  the  surgeon  to  lift 
the  fundvis  until  it  maj'  be  felt  by  the  index-finger  in  the  vagina  or  the  hand 
upon  the  abdomen. 

If  a  tumor  should  be  present,  this  may  be  palpated  between  the  two  hands, 
and  a  mental  note  made  of  its  mobility  and  consistence.  If  the  uterus  be  im- 
movable, the  indications  are  that  an  inflammatory  process  has  preceded  the  exam- 
ination, leaving  extensive  adhesion  after  the  acute  symptoms  had  subsided. 

In  the  lateral  or  Sims  jDosition  the  patient  rests  upon  the  left  side,  with  this 
hip  near  the  edge  of  the  table,  and  with  both  thighs  flexed  upon  the  abdomen, 
the  right  overlapping  and  in  front  of  the  left.  The  left  arm  is  drawn  beneath 
and  behind  the  patient  so  that  the  upper  portion  of  the  body  rests  well  over  upon 
the  chest. 

This  position  is  generally  selected  for  inspection  of  the  vaginal  wall  and  cervix 
after  the  introduction  of  the  Sims  speculum.     This  instrument,  after  being  lubri- 

602 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  603 

cated,  is  inserted  with  the  convex  surface  in  contact  with  the  recto-vaginal  septum. 
It  is  carried  in  to  its  full  depth  and  is  lield  with  firm  backward  pressure  by  an 
assistant.  While  atmospheric  pressure  dilates  the  \'aginal  tube  and  usually  brings 
the  cervix  into  plain  view,  it  is  advisable  to  lift  the  anterior  vaginal  wall  with  a 
narrow  retractor  in  order  to  obtain  as  much  light  as  possible. 

Vulvitis  nmj  be  simple,  follicular,  and  gonorrhocal.  Simple  vulvitis  is  seen 
chiefly  in  children  and  young  adults,  and  is  due  to  local  irritation  or  to  the 
presence  of  decomposing  discharges.  It  is  characterized  by  redness,  more  or  less 
swelling,  with  an  itching  or  burning  sensation  during  urination.  The  orifices 
of  the  labial  glands  are  usually  swollen  and  prominent. 

The  treatment  consists  in  irrigation  with  warm  sterile  water  or  1-5000  mer- 
curic-chloride solution,  followed  by  local  applications  with  a  mild  astringent  such 
as  four-per-cent  argyrol  or  borolyptol.  Salves  or  ointments  are  objectionable,  as 
they  tend  to  occlude  the  follicles. 

Follicular  vulvitis  is  more  apt  to  accompany  a  dyserasia  which  carries  with  it 
a  general  low  resistance,  such  as  diabetes.  The  orifices  of  the  glands  are  prominent, 
and  acne-like  pustules  are  seen  over  the  surface,  and  the  labia  are  very  much 
thickened.  Itching  is  a  marked  symptom.  The  disease  is  most  frequently  met 
with  in  women  who  have  passed  the  meridian  of  life. 

Treatment. — A  careful  urinar}'  analysis  and  blood  examination  is  essential,  and 
any  constitutional  conditions  which  they  indicate  should  be  carefully  treated.  Lo- 
cally the  parts  should  be  kept  clean,  and  an  application  of  an  ointment  containing 
five-per-cent  carbolic  acid  or  ichthyol  will  be  beneficial. 

Oonorrliwal  vulvitis  is  unfortunately  the  most  common  form.  The  urethra  is 
swollen,  and  there  is  present  a  purulent  discharge.  The  clitoris,  urethra,  and  labia 
are  red  and  swollen,  and  the  glands  of  Skene  are  unusually  prominent.  The 
glands  of  Bartholin,  when  involved,  discharge  pus  freely.  The  pus  examined  by 
Gram's  method  will,  under  the  microscope,  reveal  the  presence  of  the  gonococcus. 
In  neglected  cases  inguinal  adenitis  is  usually  present. 

Gonorrhcea  in  the  female,  while  not  infrequently  confined  to  the  vulva  and 
meatus  urinarius,  may  extend  to  the  vagina,  iTterus,  and  tubes,  and  to  the  bladder. 
The  symptoms  of  inflammation  supervene,  as  a  rule,  rapidly  after  the  contact, 
there  being  first  noticed  a  sense  of  burning  over  the  meatus  and  along  the  urethra, 
especially  severe  during  and  immediately  after  micturition.  There  soon  follows 
a  purulent  and  occasionally  a  bloody  discharge  from  the  urethra  and  vagina.  The 
diagnosis  of  gonorrhoea  in  the  female  is  not  so  easily  made  as  in  the  male,  since 
a  vaginal  discharge  not  specific  in  character  may  conceal  the  true  nature  of  the 
disease.  The  discharge  directly  from  the  meatus  is  the  most  direct  symptom  of 
gonorrhoea. 

Treatment. — The  first  essential  is  to  impress  upon  the  patient  and  attendants 
the  danger  of  infection  of  the  conjunctiva  or  of  conveying  the  disease  by  any 
method  "from  one  person  to  another.  Locally,  the  parts  should  be  irrigated  with 
1_8000  permanganate-of-potash  solution,  or  mercuric  chloride  1-10,000.  The 
vagina  should  also  be  thoroughly  flushed  with  these  solutions,  and  in  extreme  cases 
the  uretlira  may  be  carefully  irrigated,  under  no  circumstances  permitting  the 
small  soft  catheter  employed  from  going  farther  than  the  cut-off  or  constrictor 
muscle.  This  should  l^e  followed  Ijy  tlie  local  application  of  a  five-per-cent  solu- 
tion of  argyrol.     The  warm  sitz-bat'h  and  complete  rest  are  indicated. 

Specific  infection  of  the  vulvo-vaginal  glands  is  often  more  marked  on  one 
labium.  If  the  ducts  remain  patulous,  infection  may  run  its  course  and  the  glands 
resume  their  normal  function.  With  occlusion  of  the  ducts,  an  abscess  usually 
forms,  and  requires  incision  and  drainage.  Cocaine  auEesthesia  will  generally  suf- 
fice in  relieving  these  conditions. 

If  commenced  early  in  the  disease,  the  invasion  of  the  uterus  may  be  prevented ; 
this  is  of  vast  importance  since  serious  lesions  {pi/osalpinx,  sterility,  etc.)  may 
resiilt  from  infection  of  the  uterus  and  Fallopian  tubes. 

Vulvo-vaginal  abscess  may  be  caused  by  gonorrhcsal  infection.  Incision  and 
drainage  is  indicated,  and  when  by  this  method  a  cure  is  delayed,  curettage  or  a 
clean  dissection  of  the  glandular  tissues  involved  should  be  done. 


604  THE   GENITO-URINARY   ORGANS   IN   FEMALES 

Pruritus  vulvcc  is  a  distressing  and  often  an  obstinate  disease.  The  sense  of 
itcliing,  burning,  or  formication  may  be  felt  at  the  vulva,  in  the  vagina,  or  over 
the  entire  j)udendal  region.  It  is  paroxysmal  in  character;  the  attacks  may  occur 
at  all  times,  but  more  frequently  are  severest  immediately  after  the  patient  goes 
to  bed.  This  condition  is  met  with  in  females  of  all  ages,  but  is  more  apt  to 
occur  about  the  cessation  of  the  menses.  In  addition  to  superficial  lesions  of  the 
genital  organs,  displacement  of  the  uterus,  clironic  inflammation  of  the  vagina, 
or  any  disorder  of  the  deeper  organs,  may  cause  pruritus  of  the  vulva.  The  indi- 
cations in  treatment  are  to  correct  any  existing  pathological  condition.  Grailly 
Hewitt  advises  a  mixture  of  one  part  of  chloroform  to  six  of  almond  oil. 

Hernia  of  the  labium  may  be  recognized  from  the  history  of  the  case,  the 
tumor  having  first  been  noticed  above  at  the  canal  of  Nuck,  descending  more  or 
less  gradually  into  the  labium. 

Cystic  tumors  here  originate  in  the  substance  of  the  labium. 

Hernia  of  the  ovary  is  occasionally  met  with.  The  diagnosis  may  be  made  as 
follows:  In  hernia  of  the  bowel  or  omentum  an  impulse  will  be  transmitted  on 
coughing;  it  may  be  reducible;  it  is  first  observed  in  the  canal  of  Nuck,  extending 
subsequently  into  the  labium.  A  prolapsed  ovary  is  painful  on  pressure,  giving 
a  peculiar  sensation  not  met  with  in  compression  of  a  cyst  or  loop  of  intestine. 
The  character  of  a  cyst  may  be  positively  determined  by  exiDloration  with  a  very 
fine  and  thoroughly  aseptic  hypodermic  needle  and  syringe.  An  exacerbation  of 
pain  in  a  tiimor  in  this  locality,  about  the  menstrual  period,  would  suggest  the 
presence  of  a  misplaced  ovary. 

The  treatment  of  hernia  in  the  female  is  given  elsewhere.  A  prolapsed  ovary 
should  be  extir2oated,  and  a  cyst  of  the  labium  or  canal  of  J^uck  should  be 
removed. 

The  vulva  and  adjacent  cutaneous  surfaces  may  be  the  seat  of  syphilitic,  chan- 
croidal, tubercular,  and  epithelial  ulcers,  of  ulcers  resulting  from  abrasions  or 
fissures  which  have  been  in  contact  with  gonorrhoeal  virus,  a  leucorrhoeal  discharge, 
or  the  urine;  and  of  warty  excrescences  (condylomata)  and  sarcoma. 

The  primary  lesion  of  syphilis  and  the  chancroidal  ulcer  in  this  location  do  not 
diifer  materially  from  those  elsewhere  given.  Tubercular  ulcers  follow  a  chronic 
course;  they  are  irregular  in  outline,  and  are  characterized  by  a  deeper  infiltration 
of  the  subcutaneous  tissues  than  in  the  acute  forms  of  ulcers.  Epithelioma  of  the 
vulva  possesses  the  same  characteristics  as  given  for  this  condition  on  other  muco- 
cutaneous surfaces.  Condylomata  have  already  been  considered.  Epithelioma  and 
sarcoma  of  the  vulva  are  occasionally  met  with  and  demand  early  and  wide  removal 
with  the  knife. 

Treatment. — A  typical  syphilitic  ulcer  requires  no  local  treatment.  When  an 
ulcer  of  this  region  takes  on  a  phagedenic  character  it  should  be  at  once  thoroughly 
cauterized  with  the  red-hot  wire  or  Paquelin's  cautery.  If  these  agents  cannot  be 
employed,  pure  nitric  acid  will  suffice.  The  injection  into  the  tissues  beneath  and 
around  the  ulcer,  of  a  two-per-cent  solution  of  cocaine  hydrochlorate,  renders  the 
free  use  of  the  cautery  painless.  After  destroying  the  ulcer,  an  ointment  of 
cocaine  hydrochlorate,  gr.  ij;  iodoform,  gr.  j;  morph.  sulph.,  gr.  ss. ;  olei  theo- 
brom.,  q.  s.,  may  be  applied  as  an  emollient  local  anesthetic. 

Lupoid  or  tubercular  ulcers  should  be  dissected  out,  or  deeply  injected  with 
pure  liquid  carbolic  acid,  until  sloughing  is  produced.  Mild  forms  of  this  ulcer 
may  be  cured  by  scraping  with  a  sharp  spoon  or  ring-scoop,  and  repeating  this 
procedure  at  intervals  of  two  weeks,  until  cicatrization  ensues.  Epithelioma  and 
sarcoma  should  be  freely  excised.  Arsenious  acid  may  be  successfully  applied  to 
epithelial  cancer  which  has  not  extended  too  deeply  within  the  vagina.  Papil- 
lomaia  may  be  radically  destroyed  by  clipping  them  off  with  curved  scissors  and 
burning  the  stump  with  nitric  acid.  In  all  forms  of  ulcer  of  the  vulva  compli- 
cated with  vaginal  discharge,  repeated  irrigation  of  this  canal  with  warm  sub- 
limate solution   (1-5000)  should  be  practiced. 

Vulvitis  from  direct  injury  should  be  treated  by  comi^lete  rest,  aided  by  the 
sitz-bath  of  warm  water  and  hy  emollient  applications. 

Among  the  acute  surgical  lesions  of  the  labia  which  may  call  for  operation  are 


THE   GENITO-URINARY   ORGANS   IX   FEMALES  605 

lisemorrhage  from  'n'ouncls,  and  liaBmatoma  due  to  contusions,  or  to  rupture  of  a 
blood  vessel  from  an  erosion  (chancre,  etc.). 

Incised  or  lacerated  wouncts  of  tlie  vulva  are  frequently  accompanied  by  pro- 
fuse hemorrhage,  especiallj^  when  the  venous  jilexuses  which  compose  the  hidbs 
of  the  vestibule,  on  either  side  of  the  vaginal  orifice,  or  the  large  connecting  veins 
which  extend  upward  to  the  clitoris,  are  divided.  Incision  or  rupture  at  or  near 
the  median  line,  the  posterior  commissure  of  the  vulva,  is  not  followed  by  haemor- 
rhage, as  a  rule,  since  the  vascular  network  does  not  extend  so  low. 

Bleeding  may  be  arrested  by  direct  compression  with  a  pledget  of  gauze  or 
lint,  or,  in  case  of  extensive  injury,  by  tlie  ligature. 

Contusions  of  this  part  of  the  genital  apparatus  may  be  followed  by  hematoma 
or  abscess.  Hffimatoma  also  occurs  .  in  rare  instances  in  pregnant  women  from 
overdistention  and  rupture  of  the  veins  without  direct  violence. 

In  this  variet}'  of  swelling  operative  interference  is  not  advisable,  unless  the 
tumor  is  so  large  that  it  seriously  interferes  with  the  comfort  of  the  patient,  or 


Fig.  015. — Showing  arrangement  of  the  erectile  tissue  and  venous  plexuses  about  the  vulva,  a,  Bulb 
of  vestibule,  b,  Clitoris,  c,  Connecting  veins,  d,  Dorsal  vein  of  clitoris,  e,  j,  Deeper  veins. 
g,  h,  Conunumeation  between  obturator  and  vulvar  vessels.      (After  Quain.) 


unless  sloughing  is  imminent  or  suppuration  supervenes.  Boils  are  not  infrequent 
in  this  same  location,  and  require  to  be  opened,  kept  clean  by  constant  care,  and 
when  sluggish  in  healing  should  be  touched  thoroughly  with  lunar  caustic. 

As  a  result  of  injury,  and  occasionally  as  a  congenital  affection,  adhesions  of 
the  labia  exist. 

Adhesions  of  the  clitoris  are  very  frequently  seen  and  should  be  broken  up, 
since  the  retained  secretion  tends  to  decomposition  and  always  produces  a  very 
annoying  irritation.  This  may  be  accomplished  by  putting  the  parts  on  the  stretch 
between  the  thumb  and  finger  and  using  a  dull-pointed  instrument — such  as  a 
grooved  director — for  tearing  through  the  adhesions. 

Elephantiasis,  not  due  to  the  presence  of  the  filaria,  is  another  of  the  rarer 
surgical  diseases  of  the  external  genitals.  The  mass  usually  assumes  a  sessile 
shape,  and  appears  to  be  an  aggregation  of  hard  nodules.  It  should  be  treated 
by  excision. 

Vaginitis.- — By  reason  of  its  thick  protective  covering  of  sqiiamous  epithelium, 
the  vaginal  mucous  membrane  is  not  easily  infected.  While  the  gonococcus  may 
find  lodgment  here  and  produce  inflammation,  the  most  frequent  cause  of  vaginitis 
is  the  presence  of  an  irritating  septic  discharge  from  the  cervix  uteri.  It  is  more 
apt  to  be  severe  in  the  3"oung  than  in  the  middle-aged  and  old. 

Treatment. — As  a  cleansing  and  palliative  measure,  irrigation  with  a  1-8000 
permanganate-of-potash  or  1-10,000  mercuric-chloride  solution  should  be  made  two 
or  three  times  a  dav.     A  cure  cannot  be  effected  without  dealing  directly  with  the 


606  THE   GENITO-URINARY   ORGAXS   IN   FEMALES 

focus  of  infection  in  the  cervix  or  cavity  of  tlie  uterus  when  the  disease  has.  passed 
beyond  the  internal  os. 

When  ulcers  occur  upon  the  vaginal  wall,  they  should  be  touched  with  a  ten- 
per-cent  solution  of  argyrol.  In  severe  chronic  cases,  the  vagina  packed  daily  with 
five-per-cent  iodoformized  gauze  wrung  out  of  mercuric-chloride  solution,  1-10,000, 
will  bring  the  inflammation  under  control.  It  is  imperative  that  the  patient  rest 
in  bed. 

There  is  a  mild  form  of  vaginitis  which  affects  the  aged,  which  is  best  treated 
by  loose  tampons  soaked  in  lanolin  or  ichthyol.  Membranous  vaginitis,  which  is 
a  complication  of  puerperal  peritonitis,  will  be  given  elsewhere. 

Endocervicitis. — On  account  of  the  racemose  glands  which  are  found  lining 
the  cervical  canal,  this  portion  of  the  uterus  is  very  frequently  the  seat  of  infec- 
tion. It  is  especially  liable  to  chronic  gonorrhceal  inflammation,  which  is  by  far 
the  most  common  form  of  infection,  and  is  often  so  obstinate  that  amputation  is 
necessary  to  effect  a  cure.  In  gonorrhceal  endocervicitis  the  follicles  about  the 
external  os  appear  as  elevated  red  papillie,  the  cervix  is  enlarged  and  red,  and  is 
usually  bathed  in  pus.  These  patients  usually  complain  of  a  sense  of  weight  in 
the  pelvis. 

Treatment. — Vaginal  irrigation,  as  just  advised  as  a  palliative  measure,  should 
be  practiced  in  this  disease.  The  chief  reliance,  however,  is  upon  local  applica- 
tions. In  using  these  great  care  should  be  taken  not  to  convey  the  infection  to 
the  cavity  of  the  uterus.  A  pellet  of  cotton  upon  a  probe  moistened  in  mercuric- 
chloride  solution,,  1-5000,  should  be  covered  with  iodine  crystals  and  introduced 
to,  not  through,  the  internal  os,  making  a  thorough-  application  of  the  iodine  to 
the  lining  membrane  of  the  cervical  canal.  The  same  application  should  be  made 
to  the  vaginal  surface  of  the  cervix  and  a  glycerine  tampon  inserted,  or  the  deeper 
vagina  piaeked  with  iodoformized  gauze  wrung  out  of  1-10,000  mercuric-chloride 
solution.  This  should  be  repeated  every  second  day,  giving  frequent  irrigations 
on-  the  intervening  day.  Should  the  condition  become  chronic  and  obstinate, 
amputation  is  indicated. 

In  those  cases  where  cysts  are  frequently  observed  upon  the  vaginal  cervix, 
multiple  puncture,  followed  by  the  application  of  iodine,  may  effect  a  cure.  Tuber- 
culous endocervicitis  almost  always  requires  amputation.  As  this  is  but  a  local 
expression  of  a  constitutional  condition,  every  means  should  be  employed  to  im- 
prove the  nutrition  of  the  patient. 

Vaginismus,  or  "  spasm  of  the  vagina,"  is  chiefly  due  to  an  abnormally  sensi- 
tive condition  of  the  vaginal  orifice.  Vaginitis  is  not  usually  piresent.  Upon 
introducing  the  finger,  the  hymen  will  often  be  found  tense  and  resisting.  An 
effort  to  carry  the  finger  into  the  vagina  will  be  extremely  painful,  and  will  cause 
spasm  of  the  sphincter-vaginae  muscle. 

Treatment. — Place  the  anjesthetized  patient  on  the  back,  with  the  sacrum  rest- 
ing on  the  edge  of  the  table,  the  thighs  separated  and  held  by  assistants,  and  make 


Fig.  615a. — Sims  glass  vaginal  plug. 


the  antiseptic  toilet.  With  the  hymen  exposed  by  holding  the  labia  apart,  seize 
this  membrane  with  mouse-tooth '  forceps  and  dissect  it  out  close  to  its  vaginal 
attachments.  Introduce  two  fingers,  dilate  the  vagina,  and  with  the  knife  make 
two  parallel  incisions  on  the  lateral  aspects  of  the  vaginal  wall  throughout  its 
length.  These  incisions  should  extend  about  through  the  vaginal  wall.  Then 
introduce  the  Sims  glass  vaginal  plug   (Fig.  615a),  adjusting  the  instrument  so 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  607 

that  the  urethra  will  fit  into  the  concavity  on  its  upper  surface.  It  should  be 
removed  in  six  or  eight  hours,  the  vagina  irrigated  and  the  cylinder  reintroduced. 
After  the  first  twenty-four  hours  it  may  he  worn  three  or  four  hours  daily.  This 
should  be  kept  up  for  two  or  three  weeks,  or  until  all  trace  of  the  vaginismus 
has  disappeared. 

If  the  glass  plug  cannot  be  obtained,  a  moderate  packing  of  strips  of  iodo- 
formized  gauze  will  suffice.  In  mild  cases  simple  digital  divulsion  of  the  sphincter- 
vaginse  muscle  may  efl'ect  a  cure.  It  is  occasionally  associated  with  endometritis, 
ovaritis,  and  salpingitis,  and  cannot  be  relieved  until  the  deeper  lesions  are  cured. 

Stricture  of  the  Vagina. — Occlusion  of  the  vagina  may  be  partial  or  complete, 
and  may  be  congenital  or  acquired.  The  diagnosis  is  readily  luade  by  digital 
examination  or  by  inspection.  Imperforate  or  partially  obliterated  hymen  need 
not  be  mistaken  for  true  stricture,  when  it  is  borne  in  mind  that  this  membrane 
is  situated  just  at  the  entrance  to  the  vagina,  while  stricture  proper  occurs  beyond 
this  point  in  a  large  majority  of  cases.  The  exact  situation  of  the  obstruction 
may  be  readily  appreciated  by  making  a  digital  exploration  of  the  rectum,  thus 
locating  the  cervix  uteri,  while  the  other  index-finger  is  introduced  per  vaginam 
as  far  as  the  stricture.  In  complete  obstruction  (atresia),  the  absence  of  the 
menstrual  discharge  shoidd  be  considered  in  arriving  at  a  diagnosis. 

Treatment. — In  partial  occlusion,  due  to  bands  or  a  membrane,  these  should 
be  divided  or  ruptured,  a  thorough  dilatation  accoiuplished,  and  the  glass  cylinder 
of  Dr.  J.  Marion  Sims  introduced,  as  in  the  treatment  of  vaginismus.  When  there 
is  a  narrovmess  of  this  canal,  without  well-marked  contracting  bands,  it  will  suf- 
fice to  dilate  with  bougies,  gradually  increasing  in  size  until  a  cure  is  effected. 
The  operation  may  be  repeated  two  or  three  times  a  week,  or  less  frequently  should 
any  severe  infiammation  sujjervene. 

When  the  opening  is  so  small  that  the  finger  cannot  be  introduced,  a  probe- 
pointed  bistoury  may  be  carried  through  and  the  obstruction  divided  in  several 
directions,  after  which  forcible  dilatation  should  be  practiced. 

When  complete  occlusion  exists,  the  canal  shoulcl  be  opened  up  by  cutting 
through  the  adherent  walls  in  the  ascertained  direction  of  the  cervix  uteri.  By 
dilating  the  canal  as  wide  as  possible  to  the  point  of  obstruction  then  locating  the 
cervix  with  the  index-finger  of  the  left  hand  in  the  rectum,  while  the  sound  is 
kept  constantly  in  the  urethra  and  bladder  as  an  additional  guide,  the  dissection 
may  be  safely  accomplished.  The  Sims  glass  cylinder  should  be  employed  in  the 
after-treatment. 

Endometritis. — Septic  organisms  usually  find  their  way  into  the  cavity  and 
lining  membrane  of  the  uterus  by  the  extension  of  a  vaginal  or  cervical  infection. 
The  instances  are  extremely  rare  when  they  are  conveyed  by  the  blood  or  lymph 
channels.  Gonorrhceal  efidomelritis  is  one  of  the  most  serious  of  these  infections, 
not  only  dangerous  to  life  by  inducing  peritonitis,  but  almost  always  ending  in 
the  sterility  of  the  individual. 

The  onset  of  this  disease  is  marked  by  uterine  cramps,  at  first  intermittent, 
but  later  these  may  become  almost  constant.  Deep-seated  pain  is  felt  as  the 
tubes  and  peritoufEum  become  involved.  The  temperature  is  elevated  two  or  three 
degrees  beyond  the  normal,  with  a  corresponding  increase  in  the  pulse-rate.  The 
patient  rests  upon  the  back,  with  the  thighs  flexed  upon  the  abdomen. 

The  diagnosis  can  only  be  made  positive  by  a  careful  search  for  the  gonococcus 
by  Gram's  method. 

Treatment. — In  the  majority  of  cases  a  cure  cannot  be  effected.  The  gono- 
cocci  find  a  lodgment  in  the  deeper  follicles  and  layers  of  epitheliiim  beyond  the 
reach  of  any  local  applications,  and  where,  after  the  subsidence  of  the  acute  in- 
flammation, they  may  lay  dormant  for  months  or  years,  only  to  reassert  their 
virulence  under  conditions  favorable  to  renewed  proliferation.  Irrigation  of  the 
cavity  of  the  uterus  with  1-8000  permanganate-of-potash  or  1-10,000  mercuric- 
chloride  solution  is  indicated  as  a  palliative  measure.  The  operative  treatment 
will  be  considered  with  salpingitis. 

Non-specific  endometritis  may  follow  any  operative  procedure  upon  the  cervix 
or  body  of  the  uterus.     It  is  usually  of  short  duration  although  the  infection  may 


608  THE   GENITO-URINARY   ORGANS   IN   FEMALES 

travel  along  the  tubes,  and  in  i:)atients  of  low  resistance  salpingitis  and  peritonitis 
maj'  result,  necessitating  operative  intervention. 

"Puerperal  endometritis  results  from  infection,  usually  at  the  placental  attach- 
ment, as  a  result  of  the  introduction  of  staphylococci  or  streptococci.  It  often 
follows  criminal  abortions  or  even  a  normal  parturition,  in  which  strict  anti- 
septic precautions  have  not  been  taken.  In  women  who  have  suffered  from  gon- 
orrho^a.  infection  of  the  endometrium  during  or  after  labor  may,  in  rare  instances, 
occur  not^^•ithstanding  the  fact  that  the  strictest  antiseptic  practice  has  l^een  fol- 
lowed. 

The  lymphatics  are  the  principal  channels  through  which  the  infection  travels 
toward  the  broad  ligaments  and  the  peritonaeum.  The  venous  sinuses  may  also 
be  involved,  infected  coagula  being  not  infrequently  swept  into  the  circulation,  to 
form  metastases  in  the  various  organs.  From  this  incipient  lymphangitis  pelvic 
peritonitis  ensues,  which  may  become  general.  The  formation  of  abscesses  or  small 
pus  foci  in  the  body  of  the  uterus,  ovaries,  or  Fallopian  tubes  may  also  occur. 

This  process  of  infection  differs  from  that  in  gonorrhcea,  whicJi.  travels  along 
the  mucous  lining  of  the  tuhes,  to  involve  the  peritouEeum. 

Symptoms.- — Puerperal  sepsis  is  usually  ushered  in  by  a  chill  or  frequent  rigors, 
with  a  rapidly  increasing  pulse-rate  which  is  in  general  disproportionate  to  the 
rise  in  temperature,  the  latter  rarely  going  higher  than  102°  in  the  early  stages. 
Pain,  as  a  rule,  is  not  severe,  although  the  uterus  will  be  found  tender  upon 
pressure.  In  the  more  overwhelming  cases  of  infection,  the  expression  of  the 
face  is  characteristic  of  a  severe  intra-abdominal  lesion.  Upon  examination,  the 
external  and  deeper  genitals  are  swollen,  with  frequently  a  large  area  in  the  vagina 
covered  by  an  inflammatory  exudate.  It  is  a  wise  j)recaution  to  have  a  careful 
laboratory  examination  made  of  this  membrane,  and  a.ny  transudate  found  in  the 
deeper  portions  of  the  vagina. 

Albumen  is  apt  to  be  present  in  the  urine  and  careful  attention  should  be 
given  to  the  kidneys.  The  urine  should  be  tested  for  albumen  hourly,  if  necessary, 
and  ujjon  the  first  appearance  of  nephritis  saline  solution  sliould  be  introduced 
either  by  opening  a  vein  in  the  arm  or  by  permitting  the  necessary  quantity  of 
normal  salt  solution  to  flow  sloirly  into  the  colon  through  a  small,  soft  catheter, 
introduced  as  in  the  method  of  treatment  of  general  sirppurative  peritonitis  ad- 
vised by  J.  B.  Murphy  in  the  article  on  appendicitis.  As  a  heart  stimulant,  alcohol 
in  some  form  and  digitalis  seem  to  be  most  efficacious. 

The  prognosis  will  depend  upon  the  virulence  of  the  infecting  organisms  and 
the  resistance  of  the  patient.  At  times  the  onslaught  is  so  overwhelming  that 
death  ensues  from  acute  septicjemia. 

When  drainage  of  the  endometrium  has  been  secured  and  the  p)atient's  resist- 
ance is  sustained  by  careful  nutrition  and  hygiene,  the  symptoms  subside  within 
a  few  days  and  recovery  takes  j^lace  with  the  minimum  of  damage  to  the  pelvic 
viscera. 

The  treatment  of  ijuerperal  sepsis  consists  in  a  thorough  cleansing  of  the  en- 
dometrium, removing  putrid  or  dead  particles  of  placenta  or  blood  clot  with  the 
least  possible  traumatism  to  the  lining  membrane.  On  account  of  the  adhesion 
of  these  particles  and  shreds  of  the  placenta,  it  is  practically  impossible  to  remove 
all  septic  foci  by  irrigation. 

The  cavity  of  the  uterus  should  be  thoroughly  swabbed  with  five-per-cent  iodo- 
formized  gauze  and  then  loosely  packed  with  the  same  material.  Under  no  cir- 
cumstances should  a  sharp  curette  be  employed. 

With  the  cervix  patulous,  this  will  secure  the  necessary  drainage,  while  the 
presence  of  the  iodine  in  the  gauze  assures  the  best  possible  antiseptic  application. 
In  severe  cases  it  is  advisable  to  make  free  incision  through  the  posterior  cul-de-sac, 
in  order  to  drain  off  any  septic  serous  transudate. 

This  operation  is  performed  by  seizing  the  posterior  lip  of  the  cervix  with 
blunt  forceps,  making  upward  traction  and  cutting  through  with  blunt  curved 
scissors  at  the  line  of  union  between  the  neck  of  the  uterus  and  the  posterior 
vaginal  wall.  If  the  precaution  is  taken  to  cut  to  the  extent  of  about  half  an  inch 
in  the  middle  line  at  the  junction  of  the  vaginal  wall  with  the  cervix,  no  danger 


THE   GEXrrO-rEIX.^RY   ORG.Os'S   IN   FEiLlLES 


609 


can  be  done  to  any  of  the  structures.     Through  this  opening  the  gloved  finger  is 
introduced  into  the  peritoneal  cavity,  and  the  opening  dilated  laterally. 

If  adhesions  have  formed  betTveen  the  posterior  surface  of  the  uterus  and  broad 
ligaments  and  the  intestines,  they  should  be  freely  broken  up  "with  the  finger, 
keeping  the  palmar  surface  close  to  the  uterus  and  ligaments  in  order  to  avoid 
injury  to  the  walls  of  the  iatestines.  In  separating  these  adhesions  the  finger 
should  be  carried  well  out  to  the  pelvic  brim  on  either  side.  With  this  accom- 
plished and  having  removed  all  possible  fluid  and  exudate,  the  patient  shotild  be 
placed  in  the  extreme  Trendelenburg  posture.  By  lifting  the  anterior  vaginal 
wall  with  a  trowel  retractor  and  by  gentle  pressure  with  a  gloved  finger  or  a 
gauze  swab  on  long  forceps,  any  adhering  loops  of  intestine  may  be  loosened  and 
allowed  to  gravitate  out  of  the  pelvis.  The  pelvis  is  now  packed  through  the 
opening  in  Douglas'  cul-de-sac  by  the  following  method  of  the  late  Prof.  W.  E. 
Pryor:  Five-per-eent  reerystallized  iodoform  gatize  is  folded  so  as  to  make  loose 


Fig.  616. — The  Pean-Pryor  trowels  in  position,  lifting  the  uterus  and  bladder  and 
depressing  the  rectum. 


rolls  about  one  inch  wide  and  about  one  inch  longer  than  the  distance  from  the 
opening  in  the  cul-de-sac  to  the  top  of  the  fundus  of  the  uterus  and  the  broad 
ligaments.  These  roUs,  slightly  flattened,  are  introduced  through  the  vaginal 
incision,  and  carried  upward  laterally  to  the  level  of  the  broad  ligament.  Other 
pieces  are  placed  side  by  side  with  these  and  held  firmly  until  all  are  inserted, 
the  whole  making  a  dam  or  compress  of  gauze  which  entirely  shuts  off  the  pelvic 
organs  from  the  general  peritoneal  cavity.  In  order  to  place  these  properly,  it  is  best 
to  use  right-angle  retractors,  'ivith  long  thin  blades  about  one  and  one  quarter  inches 
wide.  After  the  insertion  of  each  piece  of  gauze,  the  retractor  is  withdrawn  and 
pressed  against  the  last  piece  inserted.  The  end  of  each  gauze  roU  protrudes  into 
the  vagina.  The  loose  packing  of  gaitze  in  the  uterus  should  be  withdrawn  after 
forty-eight  hours.  The  cul-de-sac  packing  shottld  be  allowed  to  remain  for  one 
week,  when  it  is  withdrawn  and  two  additional  loose  pieces  inserted  at  this  time  to 
secure  further  drainage. 

The  precaution  to  be  sure  that  no  intestinal  loops  remain  in  the  pelvis  when 
this  packing  is  inserted  should  be  emphasized,  since  intestinal  obstruction  would 
almost  inevitably  ensue.  Hence  the  necessity  for  exaggerating  the  Trendelenbtirg 
posture  and  the  careful  examination  to  determine  the  fact  that  no  intestinal  loops 
are  causht  bv  adhesion. 


610  THE   GENITO-TJRINARY   ORGANS   IN   FEMALES 

This  second  dressing  should  be  changed  every  two  or  three  days  until  the  dis- 
charge has  ceased  and  the  wound  is  nearly  closed,  at  which  time  the  cervix  is 
pressed  backward  and  held  by  a  transverse  packing  placed  immediately  over  the 
anterior  fornix.  This  packing  is  intended  to  bring  the  fundus  forward  and  restore 
the  uterus  to  its  former  position. 

Salpingitis. — The  most  common  cause  of  infection  of  the  Fallopian  tubes  is 
the  gonococcus;  less  frequently  the  streptococcus  or  staphylococcus.  Such  is  the 
virulence  of  gonorrhoeal  salpingitis  that  the  deep  layers  of  tubular  epithelia  which 
line  the  tube  are  rapidly  destroyed,  the  infecting  process  involving  the  deeper 
structures  and  the  peritoneal  covering. 

Fortunately,  the  peritoneal  opening  of  the  tube  is  almost  always  closed  by  a 
rapidly  formed  exudate,  thus  encapsulating  the  septic  focus.  Should  this  not  occur, 
the  infection  passes  immediately  into  the  peritoneal  cavity,  and  a  rapid  ascending 
peritonitis  results.  When  encapsulation  occurs  and  an  abscess  forms,  its  contents 
may  be  discharged  into  the  uterine  cavity,  to  be  drained  off  through  the  vagina. 

In  the  earlier  stages  of  infection  the  increased  weight  of  the  tube  carries  it 
into  the  deeper  pelvis,  often  with  the  attached  ovary,  where  both  are  apt  to  become 
permanently  bound  down  by  plastic  lymph. 

Symptoms. — Pain,  which  is  increased  when  standing  or  walking,  is  one  of  the 
earlier  symptoms  of  salpingitis.  As  a  rule,  the  temperature  is  not  markedly  ele- 
vated unless  general  peritonitis  has  taken  place. 

In  the  diagnosis,  careful  attention  must  be  given  to  the  history  of  the  ease,, 
and  an  examination  made  in  order  to  discover  any  indications  of  a  recent  or 
remote  gonorrhceal  infection.  Upon  a  vaginal  examination,  the  fornices  are  found 
tense  and  pressure  over  the  tubes  is  painful. 

Treatment. — The  palliative  treatment  is  rest  in  bed  in  the  Fowler  position, 
with  the  application  of  iee-bags  to  the  lower  portion  of  the  abdomen,  ancl  to  this 
should  be  aclded  vaginal  irrigation  with  1-10,000  warm  mercuric-chloride  solution. 
It  is  advised  to  keep  the  bowels  open  by  free  catharsis. 

If  at  any  time  while  these  conservative  measures  are  being  tried  there  should 
develop  well-marked  symptoms  of  a  further  spread  of  the  infection,  an  operation 
should  be  performed. 

Operative  Treatment. — The  method  of  operating  should  he  determined  by  the 
character  of  the  infection  and  the  conditions  present.  When  a  clean  operation 
may  be  performed,  the  abdominal  route  with  the  patient  in  the  Trendelenburg 
posture  gives  the  surgeon  the  most  complete  command  of  the  entire  pelvis,  enabling 
him  to  determine  accurately  by  inspection  the  extent  of  the  lesion  and  to  operate 
with  greater  safety  than  can  be  done  through  a  cul-cle-sac  incision. 

When,  however,  an  operation  is  urgent  in  an  acute  stage  of  salpingitis,  where 
there  is  more  or  less  widespread  pelvic  infiltration,  a  condition  which  usually 
demands  drainage,  a  cul-de-sac  operation  is  to  be  preferred.  The  procedure  is 
identical  with  that  described  for  drainage  in  puerperal  sepsis.  The  tubes,  as  a 
rule,  will  be  found  near  the  opening,  and  may  be  felt  surrounded  by  a  varying 
thickness  of  lymph  exudate,  which  may  be  readily  broken  up  with  the  fingers. 

The  extreme  Trendelenburg  posture,  with  the  legs  and  thighs  flexed  well  upon 
the  abdomen,  will  remove  the  coils  of  small  intestines  from  the  pelvis,  and  thus 
prevent  their  contact  with  any  septic  material  to  which  they  might  be  accidentally 
exposed  by  rupture  of  an  abscess  during  the  operation.  When  both  tubes  have 
been  loosened,  they  may  be  seized  with  a  pair  of  blunt  forceps  and  drawn  through 
the  opening  into  the  vagina,  where  they  are  clamped  with  long  forceps  close  to 
their  deep  attachment,  cut  away  with  scissors,  and  the  pedicle  tied  with  IvTo.  25 
linen,  and  an  iodoformized  gauze  pack  inserted  as  described  for  puerperal  sepsis. 
This  should  be  removed  in  five  or  six  days,  and  replaced  with  a  smaller  quantity 
of  loose  gauze,  which  is  changed  every  three  days  until  the  wound  is  healed. 

In  chronic  subacute  salpingitis,  the  suprapubic  incision  should  be  selected, 
since  it  is  often  possible  to  remove  all  septic  material,  enabling  the  operator  to 
close  the  abdominal  incision  without  drainage. 

If,  during  the  operation  by  this  incision,  the  surgeon  finds  drainage  necessary, 
the  cul-de-sac  incision  should  then  be  made  and  drainage  inserted  here. 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  611 

Ovaritis. — Primary  inflammation  of  the  ovary  is  an  exceedingly  rare  lesion. 
Infection  of  tliis  organ  results  almost  always  from  the  direct  extension  of  a  septic 
process  from  the  tubes,  body  of  the  uterus,  or  peritonEeum.  In  gonorrhoeal  en- 
dometritis it  may  be  involved  by  direct  contact  with  the  fimbriated  extremity  of 
the  Fallopian  tube,  since  the  infecting  organisms  reach  the  peritoneal  cavity  along 
the  mucous  lining  of  this  tube. 

Ovaritis  from  puerperal  sepsis  is  caused  by  the  transmission  of  the  septic  process 
along  the  lymphatic  channel.  There  may  be  a  general  infiltration,  causing  the 
organ  to  become  swollen,  heavy,  and  spongy  to  the  feel,  with  or  without  the  for- 
mation of  an  abscess. 

The  treatment  is  a  careful  removal  of  the  diseased  organ.  When  exposed  by 
incision,  sterile  mats  should  be  carefulh^  placed  so  that  in  case  of  rupture  the 
septic  contents  may  not  come  in  contact  with  other  organs.  If  any  infection  of 
the  peritonEeum  has  already  occurred,  it  is  a  wise  precaution  on  the  part  of  the 
operator  to  drain  as  just  advised  through  Douglas'  cul-de-sac.  Should  both  organs 
be  involved,  the  question  of  drainage  in  the  hope  of  preserving  the  functions  of  the 
ovary  should  be  seriously  considered. 

Infection  and  abscess  of  the  broad  ligaments  is  not  so  serious  as  that  of  the 
ovary.     Evacuation  and  drainage  through  the  cul-de-sac  is  advised. 

Dcforviities  and  Malpositions   of   the   Uterus 

Anteflexion. — In  acute  or  well-marked  anteflexion,  the  cervix  occupies  a  rela- 
tively high  position  in  the  pelvis,  owing  to  a  contraction  of  the  utero-sacral  liga- 
ment, while  the  body  of  the  uterus  lies  over  the  bladder  close  to  the  symphysis 
pubis.  With  the  vaginal  portion  of  the  cervix  in  practically  its  normal  relation 
to  the  axis  of  the  vagina,  the  deeper  portion,  or  internal  os,  is  bent  sharply 
forward. 

This  type  of  malposition  or  malformation  of  the  uterus  is  frequently  congenital 
and  produces  the  dysmenorrhoea  so  coinmon  in  younger  women  and  those  who  have 
not  borne  children. 

The  chief  subjective  symptom  is  pain,  which  commences  from  one  to  four  days 
before  the  menstrual  flow,  and  is  frequently  so  severe  as  to  cause  the  patient  to 
take  to  bed.  When  the  flow  is  established  the  acuteness  of  the  pain  is  less,  and 
in  a  majority  of  cases  it  practically  ceases  with  a  free  menstrual  discharge. 

Dysmenorrhoea  is  due  not  only  to  obstruction  in  the  cervical  canal,  but  also 
to  a  changed  condition  of  the  endometrium.  This  is  evidenced  by  the  nature  of 
the  menstrual  discharge,  which  consists  almost  altogether  of  blood,  while  in  the 
normal  condition  there  is  a  large  mixture  of  a  transudate  from  the  uterine 
IjTnphatics. 

Treatment. — The  operation  consists  in  a  thorough  dilatation  of  the  cervix 
either  by  the  introduction  of  sounds,  gradually  increasing  the  size,  or,  when  the 
cervix  is  unyielding,  by  first  making  an  incision  about  one  eighth  of  an  inch 
deep  on  either  side  at  the  site  of  the  internal  os.  This  is  best  accomplished  by 
inserting  a  curved  probe-pointed  bistoury  into  the  cavity  of  the  uterus,  drawing 
the  edge  toward  the  side  and  making  the  necessary  bilateral  incision ;  or  the  dilator 
may  be  inserted  and  careful,  forcible  dilatation  made. 

Should  there  be  the  history  of  a  persistent  leucorrhoeal  discharge,  it  is  advisable 
to  make  a  careful  curettage,  after  which  a  ribbon  of  iodoformized  gauze  should 
be  inserted  well  into  the  cavity  of  the  uterus,  where  it  is  allowed  to  remain  for 
forty-eight  hours. 

The  after-treatment  consists  in  the  introduction  of  a  sound  once  or  twice  a 
month,  in  order  to  prevent  a  recontraction  of  the  cervical  canal.  This  is  best 
accomplished  by  introducing  under  careful  asepsis  the  ordinary  curved  male  ure- 
thral sounds  as  often  as  required,  or  the  cervical  dilator  may  be  employed. 

Anteflexion  of  the  uterus,  as  well  as  the  narrowing  of  the  cervix,  is  practically 
always  benefited,  and  in  many  instances  cured,  as  a  result  of  gestation  and 
parturition. 


612  THE   GBNITO-URINARY   ORGANS   IN   FEMALES 

Retroflexion  and  Retroversion 

Backward  displacements  of  the  uterus  are  also  congenital  and  acquired.  In 
the  majority  of-  instances  there  is  a  congenital  defect  which  carries  the  fundus 
backward,  and  here,  as  a  result  of  long-continued  irritation,  due  chiefly  to  retained 
menstrual  excretion^  adhesions  are  ajDt  to  occur  permanently,  attaching  the  uterus 
to  the  jjeritoneal  covering  of  the  rectum  and  to  the  pelvic  fascia. 

For  this  condition  the  rational  metliod  of  treatment  is  an  operation  preferably 
by  the  suprapubic  route.  When  endometritis  is  present,  a  preliminary  curettage 
should  be  done.  The  patient  is  then  placed  in  the  Trendelenburg  posture  and  an 
incision  made  as  for  hysterectomy.  This  should  be  large  enough  to  permit  a 
careful  inspection  of  the  pelvic  viscera,  for  a  clear  view  is  essential  in  preventing 
injury  to  the  viscera  in  separating  adhesions. 

When  this  is  done,  all  bleeding  should  be  carefully  arrested  and  an  effort  made 
to  cover  the  raw  surfaces  left  by  separating  adhesions  with  peritonajum.  The 
uterus  is  now  carried  forward  to  as  near  the  normal  position  as  possible  and  held 
in  place  by  shortening  the  round  ligaments.  The  peritoneal  surfaces  of  the  round 
ligament  which  will  come  in  contact  when  it  is  looped  upon  itself  should  be  scraped 
with  the  scalpel  or  rubbed  harshly  with  a  gauze  swab.  It  is  then  folded  once  or 
twice,  as  may  be  necessary  to  give  the  required  shortening,  and  the  loops  stitched 
together  with  chromicized  catgut  or  fine  linen  sutures. 

When  no  adhesions  exist,  Alexander's  operation  is  much  simpler,  since  it  is 
entirely  extra-peritoneal :  This  consists  of  an  incision  which  exposes  the  external 
abdominal  ring,  between  the  pillars  of  which  and  through  the  inguinal  canal  the 
roiTud  ligament  makes  its  escape.  By  careful  dissection  this  ligament  is  found 
and  traction  made  upon  the  free  end  until  the  uterus  is  drawn  well  up  toward  the 
anterior  abdominal  wall.  .  The  round  ligament  is  then  stitched  into  the  pillars 
of  the  ring  in  this  new  position,  and  the  same  procedure  repeated  on  the  other 
side. 

If,  as  is  not  infrequent,  salpingitis  is  a  complication,  or  if  there  is  any  other 
lesion  of  the  pelvic  viscera,  this  should  be  subjected  to  operation  before  attemjjting 
to  replace  the  uterus. 

In  properly  selected  cases,  and  especially  in  women  who  have  passed  the  child- 
bearing  period,  and  in  whom  the  uterus  is  uncontracted  and  top-heavy,  ventral 
suspension  gives  very  satisfactory  results  in  not  only  relieving  the  congestion  due 
to  displacement,  but  in  giving  increased  support  to  the  bladder. 

In  the  performance  of  this  operation  an  incision  about  two  inches  long  is 
made  in  the  median  line  beginning  at  a  point  about  one  and  one  half  inches  aljove 
the  symphysis  pubis,  and  is  extended  upward.  The  uterus  is  brought  up,  grasped 
by  a  vulsellum,  and  held  in  place  while  the  sutures  are  inserted. 

A  large-sized  half-curved  Hagedorn  needle  is  threaded  with  a  strong  suture 
of  No.  3  chromicized  catgut,  and  carried  through  the  peritongeum  from  without 
in,  entering  half  an  inch  from  the  cut  edge.  It  is  then  inserted  well  into  the 
muscular  substance  of  the  fundus  of  the  uterus  from  one  side  to  the  other  on 
its  anterior  aspect,  the  needle  coming  up  through  the  peritonseiun  of  the  opposite 
side  in  the  same  relative  position  as  that  at  which  it  was  entered.  This  suture 
is  repeated  half  an  inch  farther  up,  the  needle  this  time  traveling  through  the 
posterior  aspect  of  the  fundus.  The  peritoneal  surface  of  all  that  part  of  the 
uterus  which,  when  the  ligatures  are  tightened,  will  be  brought  in  contact  with 
the  peritoneum  of  the  abdominal  wall  is  now  scarified  with  the  point  of  the 
scalpel. 

The  peritoneal  incision  is  closed  with  a  running  suture  of  ordinary  catgut,  after 
which  the  two  suspension  sutures  are  tied  and  the  ends  cut  away.  The  wound  is 
then  closed  in  the  ordinary  manner. 

Lacerations  of  the  Vagina  and  Perinwum 

These  lesions  in  practically  all  cases  result  from  parturition.  A  careful  exam- 
ination  should  be  made   immediately   after  delivery,   in   order   to   determine  the 


THE  GENITO-URINARY  ORGANS  IN   FEMALES 


613 


extent  of  any  laceration  which  may  have  occurred,  and  if  a  tear  is  present,  it 
should  be  repaired  at  once  unless  operation  is  positively  contra-indicated  by  the 
condition  of  the  patient. 

Irrigation  of  the  vagina  with  hot  1-3000  mercuric-chloride  solution  will  tend 
to  arrest  oozing  and  assure  a  more  thorough  asepsis.  If  the  rectovesical  septum 
is  extensively  torn,  salt  solution  should  be  used.  If  necessary,  packing  with  a 
ribbon  of  gauze  will  arrest  the  bleeding  from  the  cervix,  which  otherwise  would 
cloud  the  operative  field.  The  ribbon  gauze  is  preferable,  for  the  reason  that  it 
can  be  drawn  out,  as  one  unwinds  a  spool  of  thread,  after  the  operation  is  com- 
pleted, and  does  not  subject  the  line  of  sutures  to  any  strain. 

In  the  ordinary  superficial  recent  lacerations  of  the  perinteum,  after  thorough 
cleansing  silkworm-gut  sutures  are  inserted,  beginning  at  the  upper  angle  of 
the  tear.  The  needle  is  introduced  about  one  quarter  inch  from  the  margin  of  the 
wound,  taking  a  deeper  hold  if  the  tissues  have  been  badly  bruised.  It  emerges 
at  the  bottom  or  deepest  portion  of  the  wound,  is  immediately  made  to  reenter 
beneath  the  lacerated  surface,  is  brought  out  again  at  a  point  on  the  vaginal 
mucosa  corresponding  to  the  point  of  entrance. 

The  second  suture  is  introduced  about  one  third  inch  below  this,  with  its  loop 
directed  toward  the  operator,  and  so  on  until  the  woimd  is  closed.     It  is  at  times 
advisable   to   insert   intermediate   sutures   of    fine   chromicized   catgut.     If,   as   is 
usually  the  case,  an  external  tear  is  asso- 
ciated   with    an    internal,    the    opening 
remaining  on  the  skin  surface  is  now  re- 
duced  to    a    shallow   pit,    and    is    readily 
approximated  by  a  few  additional  super- 
ficial sutures.     Each  suture  should  be  tied 
as  it  is  introduced. 

These  sutures  should  be  removed  about 
the  tenth  day.  In  the  after-treatment 
Dr.  Howard  A.  Kelly  advises  that  the 
use  of  the  catheter  be  avoided  if  possible, 
and  that  the  bowels  be  opened  within  two 
days  after  the  operation.  In  order  to  pre- 
vent too  great  strain  upon  the  sutures, 
colon  irrigation  is  advised. 

The  patient  should  remain  in  bed  from 
two  to  four  weeks,  in  order  to  secure  a 
firm  union  before  the  tissues  are  subjected 
to  any  great  strain. 

Complete  rupture  of  the  recto-vaginal 
septum  is  fortunately  a  rare  occurrence. 
It  is  frequently  due  to  breech  and  other 
abnormal  presentations,  practically  all  of 
which  are  convertible  into  the  normal  by  a 
careful  study  of  the  position  of  the  fostus 
within  the  last  few  weeks  of  pregnancy. 

Complete  rupture,  however,  is  pos- 
sible with  a  normal  presentation  when  the 
head  of  the  child  is  unusually  large  or 
when  the  tissues  of  the  outlet  are  con- 
tracted and  unyielding.  An  operation  is 
demanded  as  soon  after  the  accident  as 
the  condition  of  the  patient  will  permit. 

Beginning  at  the  upper  angle,  a  row  of 
interrupted  chromicized  catgut  sutures 
should  be  inserted  upon  the  rectal  side, 
uniting  the  rectal  mucous  membrane. 
The  needle  should  be  entered  about  one  fourth  inch  from  the  torn  edge  and 
passed  deep  enough  to  engage  in  the  sulDmucous  connective-tissue  stroma.     Each 


Fig.  617. — Complete  tear  of  the  recto-vaginal 
septum  of  long  staiieling.  The  sphincter 
pits  are  seen  below  on  both  sides  of  the 
rectal  orifice,  the  shortened  sphincter  mus- 
cle is  much  tliickened,  and  there  is  a  cliar- 
acteristic  pit  just  below  it.  The  red  line 
incloses  the  area  to  be  denuded;  it  must 
not  be  forgotten  that  the  triangles  seen  ex- 
tending up  into  the  vagina  are  greatly  fore- 
shortened.     (Kelly.) 


614 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


suture  should  be  tied  as  it  is  inserted.  The  ends  of  the  torn  sphincter  muscle 
should  be  accurately  approximated,  and  for  this  purpose  one  or  two  tension  sutures 
of  silkworm  gut  are  required.  They  should  be  inserted  deeply  and  in  such  a 
manner  as  to  hold  the  divided  muscular  fibers  firmly  together.     The  vaginal  sur- 


FiG.    618. — Complete    tear    of    the    recto-vagmal 
septum.     Denudation  completed.     (Kelly.) 


Fig.  619. — Complete  tear  of  the  recto-vaginal 
septmn.  Kectal  sutures  introduced,  but  not 
tied.  Note  the  position  of  the  silkworm  gut 
tension  suture  introduced  well  behind  the 
sphincter  ends  and  passing  up  through  the 
septmn.      (Kelly.) 


face  of  the  tear  is  now  united  from 
within  outward  by  interrupted  silk- 
worm-gut sutures  one   third  inch  apart, 

inserted  at  sufficient  depth  to  insure  a  firm  hold  laterally  and  to  leave  no  tunnel 
or  trough  in  the  deeper  portions  of  the  wound. 

Each  suture  should  be  tied  as  it  is  inserted,  and,  in  order  to  insure  a  more 
perfect  approximation,  a  few  small  chromicized  catgut  sutures  should  be  inserted 
between  the  silkworm  threads. 

The  bowels  should  be  kept  open  from  the  start,  softening  the  discharges  by 
irrigation  with  warm  water,  to  which  sweet  oil  should  be  added.  The  sutures 
should  be  removed  on  the  eighth  or  tenth  day,  and  the  patient  should  remain  in 
bed  for  at  least  three  weeks. 

When  operation  has  been  delayed  after  complete  rupture  of  the  recto-vaginal 
septum,  the  changes  which  occur  are  such  that  a  different  procedure  is  necessary. 

After  a  few  weeks  the  torn  surfaces  are  contracted,  "  forming  a  sharp  ridge 
across  the  bowel,  below  Avhich  a  few  red  folds  of  everted  rectal  mucosa  project 
(looking  like  haamorrhoids,  and  sometimes  mistaken  for  them).  In  the  absence 
of  the  perineum,  the  rectum  and  vagina  have  a  common  outlet,  or  cloaca,  charac- 
teristically pentagonal  or  triangular  in  outline.  Notwithstanding  this  absence  of 
the  perinseum,  prolapse  of  the  vagina  and  uterus  rarely  occurs.  This  fact  is 
irreconcilable  with  the  view  commonly  held  that  the  function  of  the  perinseum  is 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


615 


to  plug  the  pelvic  outlet  like  a  cork.  The  correct  explanation  is  to  be  sought  in 
the  different  locations  of  the  tear;  in  most  cases  it  extends  up  the  median  line, 
and  only  branches  superficially  into  the  sulci,  leaving  the  lower  fibers  of  the 
levator  ani  muscle  uninjured.  When,  in  rare  instances,  the  ruptu.re  both  passes 
through  the  periuEeum  centrall}^  and  extends  deeply  into  one  or  both  sulci,  pro- 
lapse may  occur. 

"  The  sphincter  ani  muscle,  in  cases  of  complete  tear,  will  vary  in  form,  in 
different  cases,  from  a  simple  broken  circle,  with  its  ends  still  bound  together,  all 
the  way  to  a  shallow  arc,  in  which  case  the  muscle  is  short  and  thick,  with  a 
deep  dimple  in  the  skin  behind  it.  A  smooth,  glazed  depression,  at  times  puck- 
ered or  pitted,  at  the  lower  angle  of  the  perineal  scar  frequently  serves  as  the 
sphincter  landmark.  It  is  sometimes  difficult  to  identify  the  sphincter  ends  upon 
simple  inspection,  but  by  pulling  on  or  pinching  the  muscle  so  as  to  stimulate  a 
contraction,  the  position  of  the  ends  may  always  be  discovered." 

Dr.  Howard  A.  Kelly,^  from  whose  work  the  foregoing  is  quoted,  gives  the 
following  operative  technic : 

After  the  bowels  have  been  tlaoroughly  emptied  (preferably  by  medication  and 
irrigation),  in  order  to  prevent  contamination,  sterilized  gauze  is  pushed  into  the 


Fig.  620. — Comijlete  tear  of  the  recto-vaginal  septum.  The  rectal  sutures  all  tied  except  the  silkworm 
gut  tension  suture.  The  sutures  are  introduced  but  not  tied  in  the  right  vagmal  sulcus,  one  of 
silkworm  gut  and  two  of  catgut  above  it.      (Kelly.) 

lower  bowel,  which  is  plugged  above  the  field  of  operation.  (It  is  advisable  to 
make  the  packing  with  a  long  ribbon  of  gauze  rather  than  use  this  material  in 
bulk,  as  the  ribbon  can  be  removed  without  putting  the  line  of  sutures  on  the 

»  "Operative  Gynaecology."     D.  Appleton  and  Company,  New  York  City. 


616 


THE  GENITO-URINARY  ORGANS  IN  FEMALES 


stretch.)  Fig.  617  gives  the  general  appearance  of  an  old  case  of  complete  rup- 
ture of  the  recto-vaginal  septum.  The  posterior  vaginal  wall  at  the  upper  limit 
of  the  tear  is  here  drawn  down  bj'  contraction  until  it  occupies  the  position  of 
the  normal  perinseum. 

The  area  of  denudation  required  is  outlined  in  Fig.  617,  and  in  Fig.  618  it 
is  shown  as  completed.  The  incision  is  begun  by  splitting  from  side  to  side  the 
thin  edge  of  the  septum,  which  runs  crossways  just  over  the  anal  aperture.     This 


Fig.  621. — Complete  tear  of  the  recto-vaginal  septum.     Rectal  and  vaginal  sutures  all  introduced  and 
tied,  and  the  perineal  sutures  in  place,  but  not  yet  tied.     (Kelly.) 


incision  is  then  continued  upward  in  the  direction  of  the  upper  surface  of  the 
vaginal  opening  as  shown  in  Fig.  618.  The  angle  of  denudation,  however,  extends 
much  farther  upward  than  is  indicated  in  the  drawing.  All  of  the  mucous  mem- 
brane, together  with  all  scar  tissue,  within  the  limits  of  this  incision  is  removed 
by  the  forceps  and  scissors  (Fig.  618). 

The  manner  of  inserting  the  various  sutures  is  shown  in  Fig.  619  et  seq.  The 
material  used  is  silkworm  gut  and  chromicized  catgut.  For  the  rectal  side  of 
the  tear  only  the  catgut  is  used,  while  silkworm  gut  is  preferred  for  the  vaginal 
surface  and  for  uniting  the  ends  of  the  sphincter. 

"  The  complication  of  the  torn  bowel  is  first  disposed  of  by  a  series  of  inter- 
rupted rectal  sutures,  commencing  at  the  upper  angle  of  the  tear,  entering  each 
suture  at  the  margin  of  the  rectal  mucosa,  and  emerging  on  the  wound  surface 
about  two  fifths  of  an  inch  distant,  reentering  on  the  opposite  side  and  coming 
out  again  on  the  margin  of  the  mucosa  at  a  point  corresponding  to  that  of  en- 
trance. This  suture  may  be  tied  at  once  and  dropped  into  the  rectum,  and  so  on 
every  fifth  of  an  inch  until  the  whole  of  the  rectal  rent  has  been  obliterated  down 


THE  GENITO-URINARY  ORGANS  IN  FEMALES 


617 


to  the  sphincter.  It  is  exceedingly  important  to  secure  an  accurate  approximation 
of  the  sphincter  ends  by  two  or  three  sutures  radiating  from  the  rectal  out  on  to 
the  skin  surface.  The  contractions  of  the  sphincter  render  it  necessary  to  assist 
these  sutures  with  one  of  silkworm  gut  introduced  well  behind  the  denuded  ends 
and  passing  up  through  the  septum   (Figs.  619  and  620). 

"  The  next  step  is  the  repair  of  the  vaginal  wound  by  a  silkworm-gut  suture  in 
either  sulcus  (Fig.  620),  reaching  down  to  the  series  of  rectal  sutures  at  the 
bottom  of  the  wound.  The  loop  of  the  suture  should  lie  in  a  plane  nearer  to 
the  operator  than  its  point-s  of  exit  and  entrance,  so  as  to  lift  up  the  tissues  at  the 
bottom  of  the  wound  when  it  is  tied  (Fig.  621).  Superficial  and  half-deep  catgut 
sutures  complete  the  union  within.  There  still  remains  an  opening  on  the  skin 
sixrface,  which  is  readily  brought  together  by  a  silkworm-gut  suture,  aided  by  a 
few  superficial  or  half-deep  catgut  sutures"    (Fig.   622). 

The  after-treatment  is  the  same  as  just  giyen. 

Quite  frequently  in  women  who  have  borne  a  number  of  children  there  is, 
without  a  recognizable  rupture,  such  a  wide  relaxation  of  the  vidvo-vaginal  outlet 


Pig.  622. — Complete  tear  of  the  recto- vaginal  septum.  All  three  sets  of  sutures  introduced  and  tied,  the 
catgut  suture  cut  off  and  the  silkworm  gut  left  long.  The  outlet  is  pulled  open  a  httle  in  order  to 
show  the  inside  suture.     (Kelly.) 

that  prolapse  of  the  uterus,  or  rectocele  or  eystocele  occurs.  Either  of  these  con- 
ditions require  operation,  as  given  by  Dr.  Howard  A.  Kelly. 

"  It  is  necessary  to  exaggerate  slightly  the  effect  of  the  operation  in  narrowing 
the  vagina  in  order  to  counterbalance  a  slight  relaxation  which  always  follows. 

"  The  first  step  is  to  determine  the  limits  of  the  denudation ;  this  is  done  by 
means  of  two  tenacula  shaped  like  a  shepherd's  crook,  fixed  on  either  side  at  the 
junction  of  the  hymenal  ring,  or  its  remains,  leaving  sufficient  tissue  across  the  an- 
terior vaginal  wall  between  the  tenacula  to  make  a  small  outlet  when  the  tenacula 


618 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


are  brouo-lit  together.  These  points  mark  the  u^Dper  lateral  limits  of  the  resection 
(Fio'.  624).  If  they  are  fixed  too  near  the  urethra,  too  much  tissue  will  be  removed 
and  the  new  outlet  will  be  too  contracted;  on  the  other  hand,  if  they  are  fixed 
too  low  down,  the  new  outlet  will  continue  to  be  too  large,  notwithstanding  the 


Fig.  623. — Scheme  of  the  operation  for  complete  tear  of  the  recto-vaginal  septum  laid  on  a  flat  surface. 
The  torn  sphincter  muscle  is  indicated  by  dotted  red  lines  cross-hatched  at  each  end.  The  deep 
indentation  on  the  under  side  of  the  figure  represents  the  rectal  side  of  the  tear,  and  the  two  red 
triangles  above,  one  on  each  side,  represent  the  denudations  extending  up  into  the  vaginal  sulcus. 
The  sutures  are  passed  first  on  the  rectal  side,  A,  radiating  out  into  the  perineum,  then  in  the 
vaginal  sulci,  B,  and  finally  on  the  perineal  side,  C.  _  The  cross-marked  sutures  are  of  catgut  and  the 
plain  ones  of  silkworm  gut.  Note  especially  the  silkworm  gut  sutures  passed  in  behind  the 
sijhincter  ends  and  up  into  the  septum:      (Kelly.) 


operation.  The  correct  p)attern  to  have  in  mind  in  resecting  is  the  nuUiparous 
outlet. 

"  A  third  tenaculum  is  now  fixed  in  the  vagina  in  the  median  line  posteriorly, 
on  the  crest  of  the  vaulted  nrominenee  of  the  rectocele  or  posterior  column 
(Fig.  625). 

"  With  these  three  points  fixed,  the  area  of  denudation  must  now  be  outlined 
with  a  sharp  scalpel.  The  bloody  outline  obviates  the  liability  to  error  in  a  free- 
hand denudation.  No  one  pattern  will  fit  all  cases,  as  an  excessive  relaxation 
requires  a  more  extensive  resection  than  one  of  moderate  degree. 

"  The  surface  to  be  denuded  is  irregular  in  outline  and  occupies  several  planes, 
making  it  difficult  to  represent  it  adequately  in  a  picture.  In  making  the  outline 
the  central  tenaculum  and  one  of  the  lateral  tenacula  are  drawn  widely  apart, 
downward  and  outward,  exposing  one  of  the  vaginal  sulci.  If  there  be  a  moderate 
degree  of  relaxation  the  apex  of  the  triangle  outlined  in  each"  sulcus  is  situated 
three  centimeters  (one  and  one  fifth  inches)  within  the  outlet.  By  depressing  the 
convex  posterior  vaginal  wall  a  distinct  line  will  be  seen,  at  the  juncture  of  the 
anterior  and  lateral  walls.  An  incision  should  be  made  down  to  the  lateral  tenacu- 
lum through  the  vagina,  parallel  to  and  just  below  the  anterior  wall.  From  the 
same  point  within,  the  second  side  of  the  triangle  is  made  by  an  incision  down 
to  the  tenaculum  at  the  crest  of  the  rectocele.     A  narrow  triangular  undenuded 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


619 


area  remains  between  the  two  triangles  thus  formed  in  the  sulci  (Fig-  626).  The 
outline  is  now  completed  by  a  semicircular  incision  extending  around  the  posterior 
wall,  keeping  within  the  hymen  above,  but  embracing  any  scar  tissue  seen  below. 
The  center  of  this  line  falls  three  to  four  centimeters  (one  to  one  and  one  half 
inches)  below  the  tenaculum  -iixed  in  the  posterior  column.  The  area  thus  out- 
lined is  rapidly  denuded  with  Emmet's  right-curved  scissors,  removing  the  whole 
thickness  of  the  vaginal  walls  in  long  strips  three  to  four  millimeters  (one  tenth 
to  one  fifth  inch)  broad.  At  first  the  strip  of  tissue  follows  the  line  of  the  incision 
down  to  the  apex  of  one  of  the  triangles ;  then  it  continues  back,  and  is  carried  to  and 
fro  across  the  front,  and  up  into  the  other  triangle;  frequently  the  whole  outlined 


Fig.  024.  — 1>,  lav^.l  \.iKinal  outlet. 
Shepherd 's-crook  tenacula  fixed  in 
both  sides  just  -nithra  the  hymen, 
mark  the  limits  of  the  denudation. 
The  tenacula  are  crossed  to  sliow  the 
size  to  which  it  is  proposed  to  reduce 
the  reconstructed  outlet.     (Kelly.) 

area  can  be  removed  in  a  single 
strip.  The  dissection  is  often 
facilitated  by  running  the  ends 
of  the  scissors  beneath  the  lax 
tissue  on  the  floor  of  the  va- 
gina. Arterial  and  venous  hsem- 
orrhage  from  cut  vessels  is 
sometimes  free,  but  the  venous 
flow  lasts  only  a  short  time, 
and  ceases  spontaneously.  x\n 
actively    spoiiting    artery    should 


Il.-Pecicsi-'.'B;. 


Fig.  625. — Relaxed  vaginal  outlet.  Showing  the  shep- 
herd's-crook  tenacula  fixed  at  the  sides,  below  the  ure- 
thra, and  the  tenaculum  forceps  drawing  the  poste- 
rior columna  downward,  so  as  to  expose  the  lateral 
vaginal  walls  where  the  triangular  denudations  are 
made.     (Kelly.) 


first  be  clamped  for  a  time  in  the  artery  forceps,  and  if  it  persists  in  bleeding  after 
a  few  moments  it  may  be  tied  with  catgut.  By  judicious  application  of  the  deep 
tension  and  the  approximation  sutures,  much  haemorrhage  can  be  checked  without 
the  use  of  buried  sittures  at  all  (Fig.  627). 


THE   GENITO-URINARY  ORGANS  IN   FEMALES 


621 


"  The  large  wound  area  is  now  accurately  approximated  hj  means  of  from 
three  to  four  silkworm-gut  sutures,  and  from  eight  to  twelve  half-deep  and  super- 
ficial catgut  sutures  (chromicized).  But  one  silkworm-gut  suture  is  placed  within 
the  vagina,  in  either  sulcus.  An  assistant  exposes  one  of  the  triangular  areas  by 
drawing  the  tenactda  at  its  base  downward  and  outward;  a  carrier  is  entered  upon 
the  mucosa  on  the  lateral  vaginal  wall  near  the  incision,  a  little  below  the  middle 
of  the  triangle,  and  carried  under  the  tissue  toward  the  operator,  appearing  at 
the  bottom  of  the  sulcus,  eonsiderabl}'  below  the  point  of  entrance;  it  is  reentered 
close  by  and  carried  in  the  reverse  direction,  finally  emerging  on  the  mucosa  of  the 
opposite  side  of  the  triangle  (and  opposite  the  point  of  entrance).  A  stout  silk- 
worm-gut suture,  sharply  bent  upon  itself,  two  centimeters   (three  quarters  of  an 


Fig.  629. — Relaxed  vaginal  outlet.    Shu\\  iuf;  ho 
ering  suture  above  draws  together  the  tissues. 


.llifgath- 
(Kelly.) 


Fig.  630. — Relaxed  vaginal  outlet.  ( i]i- 
eration  completed.  Tlie  sutures  with 
longer  ends,  two  inside  and  two  out- 
side, are  of  silkworm  gut;  the  others 
are  all  of  catgut.      (Kelly.) 


inch)  from  the  end,  is  hooked  into  the  loop  of  the  carrier  and  drawn  through, 
then  pulled  up  and  tied  in  a  square  knot,  care  being  taken  to  adjust  accurately 
the  edges  of  the  wound  before  tying.  The  suture  thus  placed  draws  together  a 
large  area  of  tissue.  To  close  the  wound  accurately  above  the  suture,  its  ends 
are  grasped  between  the  third  and  fourth  fingers,  and  by  traction  the  upper  part 
of  the  triangle  is  exposed,  as  a  narrow  ellipse,  with  loosely  approximated  sides. 
Perfect  union  is  secured  here  by  fine-  catgut  sutures,  carried  deeply  from  side  to 
side.  The  first  is  placed  but  a  short  distance  above  the  one  of  silkworm  gut,  tied 
here,  and  used  in  its  turn  as  a  tractor,  exposing  the  wound  immediately  beyond; 
then  the  next  suture  is  passed  and  tied,  and  so  on  until  the  upper  part  of  the 
triangle  is  closed  and  all  bleeding  has  stopped.  The  opposite  sulcus  is  closed  in 
the  same  way  with  a  single  suture  of  silkworm  gut  and  several  of  fine  catgut. 
These  sutures  should  check  all  hfemorrhage,  but  if  there  is  persistent  oozing  it 
must  be  controlled  by  additional  svitures  tied  tightly  at  the  bleeding  point.  In 
this  way  a  large  part  of  the  resected  area  within  the  vagina  has  been  approximated, 
and  the  vaginal  canal  markedly  narrowed  within  the  pelvis.     When  the  triangular 


622 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


areas  in  the  sulci  are  large,  a  half-deep  catgut  suture  should  be  added  below  the 
one  of  silkworm  gut.  Most  of  the  remaining  area  may  be  brought  together  by  a 
single  gathering  suture  of  silkworm  gut,  embracing  the  up2Der  angles  on  the  sides 
and  transfixing  the  rectocele   (Fig.  628). 


Opening  of  the  urethi  a 
Opening  of  tlie  vagina 


Perineal  body. 


Fig.  631. — Showing  in  perpendicular  section  the  relations  of  the  perineal  body  to  the  bladder,  vagina,  and 
rectum.     (After  Thomas.) 

"  An  additional  silkworm-gut  suture  may  sometimes  be  necessary  on  the  skin 
surface  extending  through  to  the  bottom  of  the  wound.  Half-dee}^  and  su23erficial 
sutures  will  complete  the  imion  (Figs.  639,  630). 


Fig.  632. — The  same  after  rupture  of  the  perinaeum  and  the  prolapse  of  the  bladder  and  rectum 
(cystocele  and  rectocele).      (After  Thomas.) 

"  The  external  sutures  should  be  removed  from  the  eighth  to  the  tenth  day. 
Those  in  the  inside  may  remain  several  weeks. 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  623 

"  The  immediate  result  of  this  operation  is  a  complete  restoration,  and  even  the 
hymen  is  often  restored.  Subsequent  labors  will  not  destroy  the  effects  of  the 
operation,  unless  unskillfully  conducted  or  attended  by  complications." 

Figs.  631  and  632  show  in  perpendicular  section  the  relations  of  the  various 
organs  before  and  after  rupture  of  the  perinsum. 

The  Vagina 

Aisence  of  the  vagina  is  a  congenital  affection  which  scarcely  comes  within 
the  domain  of  the  general  surgeon. 

An  anomaly  equally  rare  and  yet  operative  in  character  is  that  of  double  vagina. 
There  is  a  middle  line  septum  which  usually  divides  the  canal  into  two  chambers 
of  about  equal  caliber. 

The  operative  jorocedure  consists  in  a  division  of  the  septum  along  the  middle 
line  throughout  its  entire  extent.  The  htemorrhage  is  usually  not  severe,  but  can 
be  controlled,  by  packing  with  sterile  gauze  or  by  a  running  loop  of  chromicized 
catgut  suture. 

Imperforate  hj-men  is  a  more  frequent  congenital  defect,  and  is  readily  recog- 
nized by  careful  inspection,  and  may  be  cured  by  incision,  either  dissecting  out 
the  membrane  near  its  vulvo-vaginal  attachment  or  by  making  a  crucial  incision, 
leaving  the  angles  to  retract  and  undergo  atrophy. 

In  imperforate  hymen  there  is  usually  a  collection  of  thick  fluid,  dark  in  color 
due  to  retained  menstrual  flow.  This  fluid  should  be  thoroughly  removed  by 
sponging  or  irrigation,  and  frequent  post-operative  antiseptic  irrigation  is  advised 
to  prevent  possible  septic  absorption. 

Of  the  neoplasms  of  the  vagina,  the  cystic  variety  is  more  frequently  encoun- 
tered. They  may  grow  from  either  wall,  and  occasionally  have  a  thick  covering 
which  renders  them  not  easy  of  recognition.  Aspiration  with  a  delicate,  clean 
needle  is  the  surest  method  of  diagnosis. 

These  tumors  should  be  removed,  the  sack  being  thoroughly  dissected  out. 

Abscess  of  the  recto-vaginal  septum  is  a  rare  form  of  infection.  The  swelling 
is  perceptible  by  vaginal  as  well  as  rectal  examination,  and  should  be  removed 
by  incision,  preferably  from  the  vaginal  side.  Drainage  should  be  established  until 
the  cure  is  complete. 

Of  the  solid  neoplasms  of  the  vagina,  sarcoma,  carcinoma,  and  myoma  are 
occasionally  observed.  The  malignant  tumors  may  be  differentiated  by  microscop- 
ical examination,  and  together  with  the  non-malignant  should  be  removed  as  soon 
as  discovered. 

The  surgical  lesions  of  the  female  ureihra  are  rare.  One  of  the  most  frequent 
is  caricncle,  which,  according  to  Dr.  Howard  A.  Kelly,  is  histologically  made  up 
of  connective  tissue  and  hypertrophied  papillfe,  with  numerous  dilated  vessels, 
covered  with  pavement  epithelium.  It  appears  as  a  small,  warty-like  growth, 
usually  red  in  color,  and  is  almost  always  exceedingly  painful  to  the  touch. 

Dr.  Kelly  recommends  the  thorough  extirpation  of  the  tumor,  preferably  by 
removal  with  the  knife,  and  with  cocaine  anesthesia.  After  infiltration  with 
cocaine,  it  should  be  seized  with  the  forceps  and  cleanly  dissected  from  its 
base.  Hsemorrhage  may  be  controlled  by  chromacized-catgut  sutures  or  by  the 
ligature. 

The  various  lesions  of  the  female  bladder  do  not  differ  materially  from  those 
of  the  other  sex,  and  will  be  given  in  the  general  chapter  devoted  to  the  surgical 
lesions  of  this  organ. 

The  one  procedure  which  belongs  more  particularly  to  gynecological  surgery 
is  that  of  vesico-vaginal  fistula.  The  operation  for  the  cure  of  this  distressing 
affection  was  introduced  and  first  successfully  performed  by  Dr.  J.  Marion  Sims, 
of  Montgomery,  Ala.     It  is  performed  as  follows: 

The  edges  of  the  fistulous  opening  are  pared  with  sharp-pointed,  one-half-curved 
scissors,  the  patient  resting  usually  in  the  Sims  position,  with  the  vagina  dilated 
by  a  large,  duck-billed  speculum.  The  freshening  should  extend  well  into  the 
sound  tissue.     The  opening  thus  made  is  closed  by  silkworm-gut  sutures,  inserted 


624 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


about  one  eighth  of  an  inch  from  the  margin  of  the  -n-oimd.  The  needle  is  made 
to  come  out  between  the  mucous  membrane  and  the  muscular  layer  of  the  bladder 
wall,  to  enter  and  be  brought  out  in  the  same  relative  position  on  the  opposite 
side    (Fig.   633).     The  sutures  should  be  about  one  fifth  of  an  inch  apart,  and 


Fig.  633. — Classieal  operaUon,  sutures  inserted  transversely,  instead  of  vertically.     (Kelly.) 


any  puckering  of  the  vaginal  mucosa  between  any  two  sutures  should  be  closed 
by  a  ver}'  fine  intermediate  suture  of  chromicized  catgut. 

Kelly  advises  "  the  introduction  of  a  soft  gauze  pack,  to  give  gentle  support 
to  the  vaginal  wall  and  base  of  the  bladder.  A  soft-rubber  catheter  is  left  in  the 
bladder  for  from  four  to  seven  days,  according  to  the  size  of  the  fistula.  The 
vaginal  pack  should  be  replaced  when  it  becomes  soiled.  The  bowels  should  be 
opened  on  the  third  day  by  giving  a  purgative,  followed  by  an  enema.  The  silk- 
worm-gut stitches  may  be  removed  in  twelve  to  fifteen  days." 

Prolapse  of  the  anterior  vaginal  wall,  or  cystocele,  may  be  relieved  by  dissect- 
ing ofl:  the  vaginal  layer  of  the  vesico-vaginal  septum  over  an  area  of  sufficient 
size,  and  uniting  the  edges  of  this  wound  in  such  manner  as  to  shorten  the  vaginal 
arch  and  hold  the  bladder  up  in  its  normal  position. 

The  outline  of  the  bladder  wall  is  accentuated  and  the  separation  of  the  vaginal 
layer  from  the  bladder  is  more  easily  accomplished  after  a  small  qiiantity  of  liquid 
(normal  salt  solution,  five  or  six  ounces)  has  been  injected.  The  cervix  is  grasped 
with  traction  forceps  drawn  do'wn  to  the  vaginal  outlet,  and  lateral  retractors  in- 
troduced. A  longitudinal  median  line  incision  is  made  through  the  vaginal  half 
of  the  vesico-vaginal  wall  extending  from  the  anterior  limit  of  the  cystocele  (usu- 
ally about  one  inch  from  the  urethral  meatus,  where  the  internal  urethral  orifice 
is  located)  to  the  cervix.  The  vaginal  layer  of  the  vesico-vaginal  wall  is  carefully 
separated  from  the  bladder  well  out  into  the  lateral  fornices  and  from  the  cervix 
uteri  up  to  the  peritoneal  reflection.  A  self-retaining  soft-rubber  catheter  is  car- 
ried into  the  bladder  and  its  contents  evacuated.  The  flaps  lifted  on  either  side 
of  the  median  incision  are  now  trimmed  a  sufficient  distance  on  either  side  to 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


625 


take  in  the  slack  of  the  anterior  vaginal  i^-all.  In  order  to  insure  aceurac}'  one 
or  two  trial  sutures  may  be  inserted  to  determine  just  how  much  narrowing  of  the 
vaginal  roof  is  necessary  to  give  the  proper  support  to  the  bladder.  Chromicized 
catgut  sutures  are  used  to  approximate  the  raw  edges.  Beginning  at  the  cervix, 
the  needle  should  pass  through  a  strip  of  the  anterior  cervical  wall  as  far  up  as 
the  peritoneal  reflection  beyond  which  point  only  the  two  flaps  are  sutured.  The 
self-retaining  catheter  may  remain  for  four  days  to  guard  against  overdistention 
of  the  bladder  which  otherwise  might  interfere  with  firm  union.  A  light  vaginal 
gauze' pack  should  be  employed  for  the  same  length  of  time.  Vaginal  irrigations 
of  1-3000  mercuric-chloride  solution  may  be  made  daily. 

Cervix  Uteri. — Lacerations  of  the  cervix  may  be  classified  as  unilateral,  bilat- 
eral, anterior,  posterior,  and  stellate.  They  are  also  complete  or  incomplete.  The 
bilateral  variety  is  most  frequent,  the  unilateral  next,  the  remaining  forms  being 
comparatively  rare.  In  a  complete  laceration,  the  tear  extends  through  all  the 
tissues  of  the  cervical  wall  into  the  vaginal  vault;  the  incomplete  variety  extends 
into  but  not  through  the  wall  of  the  cervix. 

The  principal  indications  for  operative  interference  are  pain,  constant  in  char- 
acter, either  local  or  reflex,  hypertrophy  or  thickening  of  the  tissues  of  the  cervix, 
as  a  result  of  granulations  along  the  line  of  the  laceration,  cystic  degeneration  of 
the  cervix,  sterility  from  occlusion  of  the  internal  os,  inability  to  carry  the  foetus 
to  term,  etc.  The  danger  of  epithelioma,  resulting  from  prolonged  irritation  of  a 
fissured  surface,  should  never  be  lost  sight  of.  The  preparation  of  the  patient 
has  been  given.  When  the  narcosis  is  complete,  she  is  placed  in  the  Sims  position 
and  a  large  Sims  speculum  introduced.  A  strong  tenaculum  should  now  be  hooked 
securely  into  the  soimd  joortion  of  the  cervix  and  the  uterus  drawn  toward  the  vulva. 
A  second  tenaculum  is  firmly  inserted  at  the  edge  of  the  rent,  the  margin  of  which 
is  now  trimmed  off  with  the  Sims  adjustable  knife,  or,  if  this  is  not  at  hand, 
Emmet's  cervix  scissors.     In  freshening  the  edges  of  the  laceration,  the  section 


Fig.  034. 
Sims'  speculum. 


should  extend  thoroughly  into  the  angle  of  the  tear,  and  all  cicatricial  or  granu- 
lating surfaces  should  be  most  carefully  removed.  AVhen  the  tissue  along  the  line 
of  the  tear  is  densely  cicatricial,  it  must  be  deeply  excised,  since  restoration  of  the 
cervical  canal  cannot  be  accom23lished  when  the  cicatrix  remains. 

When  a  bilateral  laceration  exists,  the  denuded  area  should  extend  well  out  to 
the  vaginal  surface  of  the  cervix  and  inward  to  the  level  of  the  internal  os,  or 
remaining  cervical  canal.  It  is  usual  to  leave  unfreshened  a  space  of  about  one 
fourth  of  an  inch  wide,  as  shown  at  a  a,  Fig.  635,  which  space  corresponds  to  the 
canal  to  be  restored  by  the  operation.  The  opposite  fissure  is  prepared  in  the  same 
manner,  and  the  wire  sutures  are  then  inserted.  The  most  suitable  needle  is  short 
and  strong,  with  a  slight  cutting  edge  on  one  side,  this  cutting  edge  limited  to 
the  first  one  fourth  of  an  inch  from  the  point.  This  should  be  armed  with  the 
silkworm  gut,  and  passed  through  the  vaginal  portion  of  the  cervix,  one  fourth 
of  an  inch  from  the  edge  of  the  wound,  and  brought  out  barely  within  the  unde- 
nuded  area  a  a  left  to  form  the  walls  of  the  canal  {1,  1,  Fig.  635).  The  deep 
suture — that  in  the  angle — should  be  first  inserted.  When  all  the  sutures  are 
passed,  they  should  be  tied  in  the  order  of  insertion.  It  is  important  to  bring 
the  freshened  surfaces  accurately  together. 

After  the  sutures  are  all  tied,  they  should  be  cut  at  one  fourth  of  an  inch  from 


626 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


the  line  of  union  and  a  sound  introduced,  to  see  that  the  canal  is  not  by  accident 
occluded. 

The  iDatient  should  be  put  to  bed  and  kept  perfectly  quiet  and  the  sutures 
removed  on  the  eighth  or  tenth  day.  This  is  accomplished  by  placing  her  in  the 
same  position  as  for  the  operation,  cleansing  the  parts  thoroughly,  lifting  the  deep- 


'4    .   '3       '2       li         / 

Fig.  635. — Showing  the  area  of  denudation  and  the  method  of  passing  sutures  in  bilateral 
laceration  of  the  cervix.     (Mund^.) 

est  suture  with  the  forceps  until  one  side  of  the  loop  is  seen,  and  then  dividing 
this  with  the  sharp-pointed  scissors.  Great  care  and  considerable  skill  are  neces- 
sary to  prevent  the  tearing  apart  of  the  freshly  united  surfaces.  The  patient 
should  remain  in  bed  for  a  week  or  ten  days  longer.  AVhen  cystic  degeneration 
exists  with  a  single  or  double  laceration  it  is  advisable  to  substitute  one  of  the 
following  methods  of  amputation  of  the  torn  and  diseased  cervix. 

Ampuiation  of  the  Cervix. — This  procedure  is  also  recommended  in  hypertro- 
phy of  the  cervix  and  general  cystic  degeneration.  Cystic  degeneration  is  caused 
by  connective-tissue  hyperplasia  resulting  from  chronic  infectious  inflammation,  the 

new  tissue  occluding  the  glandular 
outlets,  and  causing  a  retention  of 
their  normal  secretion,  which  may  re- 
main a  clear  fluid,  but  in  the  majority 
of  cases  undergoes  jjyogenic  infection. 
Not  only  the  glands  of  the  super- 
ficial, but  of  the  deeper  part  of  the 
cervix,  are  involved.     As  a  result  of 


Fig.  636. — Wedge-shaped  amputation  of  the  cervix  Fig  637  — 11  i     i  1 1     sutures 

uteri.   ("American  Text-book  of  Gynaecology.")  ul  UlJ 

the  retained  secretion  and  the  hyperjDlasia  the  cervix  is  greatly  increased  in  size. 
When  the  hypertrophy  or  degeneration  is  extensive,  and  it  becomes  necessary  to 
sacrifice  practically  all  the  tissues,  the  wedge-shaped  operation  should  be  performed 
as  follows:  A  double  volsella  is  fastened  into  the  anterior  and  posterior  lips  of  the 
cervix  and  the  uterus  dragged  down  until  the  cervix  is  near  the  orifice  of  the  vulva. 
A  short,  broad  speculum  and  retractors  may  be  used  when  needed.  With  a  knife 
or  sharp-pointed  scissors  the  cervix  is  completely  incised  on  either  side  almost  to  the 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  627 

cervico-vaginal  junction.  Depressing  the  anterior  lip  with  the  volsella,  a  transverse 
incision  is  made  across  this  lip  from  right  to  left,,  the  knife  being  .inserted  from  one 
quarter  to  one  half  inch  from  the  margin  of  the  cerYico-vaginal  jimction.  The  di- 
rection of  the  cut  should  be  upward,  passing  a  little  more  than  half-way  through  the 
thickness  of  the  cervix.  The  knife  is  then  withdrawn,  the  anterior  lip  raised,  and 
an  incision  made  parallel  with  this  on  the  inner  or  mucous  surface  of  the  cervix. 
In  this  way  a  wedge-shaped  section  is  removed,  leaving  a  trough  on  the  stump 
which  remains.  The  same  incision  is  made  on  the  lower  or  posterior  lip  of  the 
cervix  at  the  same  plane,  and  sutures  are  inserted  in  order  (Fig.  636)  to  bring 
the  edges  of  the  wound  together,  leaving  a  partial  cervical  canal  lined  with  normal 
mucous  membrane.  The  destruction  of  the  cervical  mucous  membrane  is  always 
to  be  avoided  for  the  reason  that  it  never  reproduces  itself,  as  does  the  endome- 
trium. After  the  sutures  are  inserted,  the  condition  of  the  parts  is  as  shown  in 
Fig.  637.  When  endometritis  is  present,  this  should  be  cured  by  curettage  at  least 
one  week  before  the  operation  on  the  cervix. 

Curettage  is  performed  as  follows:  The  uterus  is  pulled  down  with  the  double 
volsella  and  the  direction  of  the  cervical  canal  determined  by  the  sound.  In  the 
case  of  a  narrow  cervix,  it  should  be  incised  on  both  sides  by  introducing  a  curved, 
probe-pointed  l5istour3\  The  dilator  is  next  introduced  and  the  cervix  gradually 
and  intermittently  stretched.  In  the  nuUiparous  uterus,  a  dilatation  of  half  an 
inch  will  be  sufScient.  In  multipara  a  larger  opening,  being  readily  secured,  is 
desirable.  The  uterus  is  now  irrigated  with  sterilized  one-per-cent  salt  solution 
or  a  1-8000  permanganate-of-potash  solution.  A  curette  is  introduced  and  carried 
back  to  the  fundus  and  withdrawn  in  the  axis  of  the  uterus,  making  moderate 
pressure,  but  not  sufficient  if  a  sharp  curette  is  employed  to  penetrate  into  the 
muscular  substance.  Eepeating  this  manceuvre  so  as  to  cover  the  entire  cavity, 
the  whole  endometrium  is  scraped  off.  Particiilar  attention  should  be  paid  to  the 
deep  angles  where  the  Fallopian  tubes  enter,  and,  in  order  to  reach  these,  a  smaller 
curette  is  sometimes  required.  The  furrow  across  the  fundus  uteri  is  scraped  by 
carrying  the  curette  transversely  from  one  tubal  orifice  to  the  other.  The  curet- 
tage should  not  be  so  forcibly  applied  to  the  cervical  canal  as  to  destroy  the 
mucous  membrane,  which,  unlike  that  of  the  uterus,  is  not  reproduced.  The  cavity 
of  the  uterus  should  be  thoroughly  dried  or  mopped  with  small  tampons  of  iodo- 
form gauze  on  forceps,  after  which  it  is  packed  full  of  gauze,  using  by  preference 
a  single  long  ribbon.  A  small  uterus  will  hold  about  one  yard  of  gauze  one  inch 
wide.  In  the  after-treatment,  if  the  patient  can  empty  the  bladder  every  six  hours 
she  should  be  permitted  to  do  so;  otherwise  the  catheter  should  be  used.  In  non- 
septic  cases,  the  gauze  should  be  allowed  to  remain  five  days.  In  pus  cases,  it 
should  be  removed  in  three  days.  If  the  uterus  does  not  measure  more  than  four 
inches  in  depth,  it  need  not  be  packed  a  second  time,  but  in  organs  of  greater 
depth  than  this  a  second,  and  often  a  third  packing  may  be  necessar}^  When  the 
packing  is  removed,  if  the  uterus  is  practically  dry,  irrigation  is  not  necessary. 
The  patient  may  be  allowed  out  of  bed  on  the  sixth  or  seventh  daj^  The  vagina 
should  be  carefully  packed  with  iodoform  gauze,  changing  the  packing  about 
every  two  days  for  three  or  four  weeks  after  this  operation  in  order  to  prevent 
infection. 

Inversion,  in  which  the  uterus  is  turned  inside  out  and  prolapses  ^  into  the 
vagina,  occurs  usually  after  parturition,  when  the  process  of  contraction  of  the 
muscular  tissue  of  this  organ  is  insufficient,  and  the  cervix  remains  so  widely 
dilated  that  the  fundus  falls  into  and  passes  through  it.  It  is  recognized  by  the 
presence  of  a  pear-shaped  mass,  seemingly  covered  with  granulations  which  bleed 
readily  and  which  fills  the  vagina  or  may  protrude  beyond  the  vulva. 

An  effort  should  be  made  to  replace  it  by  pressing  with  one  finger  in  the 
center  of  the  projecting  mass  steadily  backward  in  the  axis  of  the  normal  position 
of  the  uterus.  Complete  narcosis  is  essential,  and  considerable  time  may  be 
required  to  dilate  the  cervix  sufficiently  to  allow  an  entire  restoration  of  the  uterus 
to  its  normal  position.  Once  replaced,  it  is  necessary  to  hold  it  in  position  by 
artificial  support,  usually  a  sterile  gauze  packing  placed  in  the  cavity  of  the  uterus 
and  vagina.     This  should  be  changed  in  two  or  three  days,  and  a  smaller  packing 


628  THE   GENITO-URINARY   ORGA^TS   IN   FEMALES 

inserted  until  the  uterus  contracts.  In  changing  the  dressing  care  should  be  taken 
to  prevent  the  prolapses  from  recurring. 

Myoma  of  the  Uterus. — Uterine  fibroids  are  new  formations  of  unstriated 
muscle  which  contain  a  variable  quantity  of  connective  tissue.  When  the  latter 
element  predominates,  they  are  called  fibro-myoma,  or  fibroids. 

They  are  rarely  present  before  maturity,  and  may  develop  within  the  muscular 
substance  of  the  wall  of  the  uterus,  where  they  usually  become  encapsulated  (inter- 
mural),  or  on  the  surface  of  the  uterus  just  under  the  peritouEeum  (extramural). 
When  they  grow  from  the  internal  surface  of  the  uterus  and  project  beneath  the 
mucous  membrane  into  the  cavity  of  this  organ,  they  are  called  submucous  myoma 
(intramural). 

Growing  from  the  peritoneal  surface  of  the  uterus,  they  may  be  round  or  ses- 
sile in  shape  or  attached  by  a  stem  or  pedicle  of  varying  length  and  thickness  to 
the  wall  of  the  uterus.  This  form  of  tumor  at  times  becomes  strangulated,  and 
may  undergo  rapid  necrosis  as  a  result  of  a  twist  of  the  pedicle. 

The  sulimucous  fibroids,  especially  those  situated  near  ,  the  internal  os,  very 
frequently  cause  profuse  hasmorrhage.  In  mural  fibroids  there  are  found  at  times 
numerous  small  cysts  caused  by  dilatations  of  the  lymphatic  vessels. 

In  general,  uterine  fibroids  are  of  firm  consistency  and  more  or  less  encapsu- 
lated, the  chief  blood  supply  being  found  in  close  relation  to  the  capsule. 

Symptoms. — Fibroids  of  the  iiterus,  especially  those  growing  beneath  the  peri- 
toneum, may  be  present  for  months  or  years  without  attracting  the  attention  of 
the  patient  or  physician  until  they  have  grown  so.  large  as  to  produce  pressure 
symptoms. 

In  the  submucous  variety,  by  reason  of  a  progressive  increase  in  the  amount 
of  blood  lost  at  each  menstrual  period,  they  may  be  recognized  earlier.  The  intra- 
mural fibroids  are  also  liable  to  induce  menorrhagia. 

Loss  of  blood  is  in  no  way  proportionate  to  the  size  of  a  tumor,  being  chiefly 
due  to  its  location  near  the  internal  os.  Moreover,  those  neoplasms  which  project 
into  the  cavity  of  the  organ  are  more  apt  to  cause  uterine  cramps,  especially  during 
the  menstrual  period,  than  the  suljperitoneal  growths. 

Intraligamentous  fibroids  are  apt  to  j)roduce  pain  in  the  hip-joint  by  pressure 
upon  the  obturator  nerve.  When  the  neoplasm  is  situated  on  the  anterior  wall, 
pressure  upon  the  bladder  often  causes  cystitis,  while  if  it  is  on  the  posterior  wall, 
and  resting  on  the  rectum  or  sigmoid  colon,  it  may  induce  constipation,  and  at 
times  colitis  and  hajmorrhoids. 

When  the  tumor  becomes  of  large  size,  pressure  upon  the  iliac  veins  is  apt  to 
cause  varicosities  in  the  legs,  with  more  or  less  oedema.  In  those  cases  in  whiclr 
the  tumor  rises  rapidly  out  of  the  pelvis,  these  earlier  pressure  symptoms  are 
not  present. 

The  treatment  of  fibroids,  which  is  operative,  will  be  considered  in  the  chapter 
on  abdominal  and  vaginal  hysterectomy. 

Carcinoma. — Cancer  of  the  uterus  in  about  ninety  per  cent  of  all  cases  is 
located  in  the  cervix.  It  is  met  with  usually  between  the  fortieth  and  fiftieth 
years  of  life,  is  exceedingly  rare  in  women  under  thirty,  but  not  infrequently 
occurs  after  the  fiftieth  year. 

It  is  in  all  probability  caused  by  a  more  or  less  constant  irritation  due  to 
lacerations  which  have  not  been  cured  by  operation,  and  to  acrid  or  irritating 
discharges  in  contact  with  even  slight  abrasions.  Microscopicall}',  uterine  cancer 
is  of  the  epithelial  type  (epithelioma).     Adeno-carcinoma  is  comparatively  rare. 

The  new  epithelial  tissue  grows  rapidly,  is  of  low  resistance,  and  readily  under- 
goes disintegration.  The  rank  growth  gives  the  lesion  a  cauliflower-like  appear- 
ance, and  often  completely  covers  and  conceals  the  vaginal  cervix.  It  bleeds  pro- 
fusely under  the  slightest  provocation. 

Infiltration  of  the  contiguous  wall  of  the  vagina,  the  bladder,  and  rectum  occurs 
early  in  the  history  of  the  disease.  Metastases  take  place  through  the  lymphatic 
channels  at  an  early  period,  a  fact  which  adds  to  the  hopelessness  of  a  cure,  unless 
:a  thorough  extirpation  is  done  within  the  first  few  weeks  of  the  appearance  of  the 
epithelioma. 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  629 

Adeno-carcinoma  is  nsiially  located  higher  up  in  the  cervical  canal  or  in  the 
body  of  the  uterns,  and  is  often  far  advanced  before  the  attention  of  the  patient 
or  physician  has  been  called  to  it. 

The  lining  membrane  of  the  deeper  portions  of  the  cervix  is  frequently  broken 
down,  while  the  external  os  is  practically  normal  in  appearance.  By  reason  of 
its  location  in  the  upper  portion  of  the  cervical  canal,  this  variety  of  uterine  cancer 
is  more  apt  to  involve  the  bladder  early  in  its  development  than  epithelioma  of 
the  vaginal  cervix. 

Symptoms. — The  first  symptom  usually  observed  in  uterine  cancer  is  leucor- 
rhoea,  which  gradually  increases  and  has  a  penetrating  and  offensive  odor,  due  to 
the  putrefactive  changes  in  the  particles  of  the  new  growth  which  are  cast  off. 
This  discharge  is  more  profuse  in  adeno-carcinoma  than  in  epithelial  carcinoma. 

Pain  is  as  a  rule  not  severe,  and  may  not  be  present  in  the  early  stages.  Later, 
when  the  bladder  or  rectum  becomes  involved  by  extension,  cystitis  or  proctitis 
results. 

The  diagnosis  is  usually  not  difficult  when  the  neoplasm  is  situated  at  the 
external  os.  It  may  be  made  positive  by  the  removal  of  a  section  and  immediate 
examination  under  the  microscope.  Adeno-carcinoma  of  the  deeper  cervix  or  of 
the  endometrium  and  body  of  the  uterus  is  rarely  recognized  until  lymphatic  infil- 
tration has  taken  place.  In  the  differentiation  between  an  epithelial  ulcer  and 
one  due  to  syphilis  or  tuberculosis,  or  of  a  polypus  which  is  undergoing  disintegra- 
tion, the  following  points  sliould  be  borne  in  mind : 

A  careful  history  of  the  case  will  determine  whether  or  not  the  patient  has 
suffered  a  syphilitic  infection.  The  ulcer  of  syphilis  does  not  bleed  so  readily 
as  that  which  is  caused  by  epithelioma.  Tuberculous  ulcers  are  pale  in  color,  not 
apt  to  bleed,  and  their  borders  are  serpiginous.  The  presence  of  a  polypus  may 
be  determined  by  dilatations  of  the  cervix,  after  which  the  tumor  may  be  traced 
back  to  its  attached  pedicle. 

The  prognosis  is  in  general  unfavorable,  for  the  reason  that  lymphatic  infiltra- 
tion will  have  occurred  before  the  ulcer  has  been  recognized,  making  a  thorough 
extirpation  practically  impossible.  It  is  only  favorable  when  the  tumor  is  located 
in  the  fundus  of  the  uterus  and  a  complete  hysterectomy  has  been  performed  before 
lymphatic  metastases  have  occurred,  or  when  with  the  first  appearance  of  an  ulcer 
of  the  cervix,  the  entire  neck  of  the  uterus  has  been  amputated. 

Treatment. — In  this  operative  procedure  (for  incipient  epithelial  ulcer  of  the 
OS  and  cervix)  vaginal  hysterectomy  is  advised,  and  the  Paquelin  cautery  knife 
should  be  used.  Clamps  or  ligatures  may  be  applied  laterally  to  the  broad  liga- 
ments and  tubes. 

Even  in  more  advanced  cases,  where  infiltration  is  so  extensive  that  a  cure  is 
impossible,  amputation  of  the  cervix  with  a  Paquelin  cautery  will  often  render  the 
patient  less  uncomfortable,  and  do  away  with  much  of  the  disagreeable  odor  of 
the  discharge. 

In  the  treatment  of  inoperative  cases  of  cervical  epithelioma,  the  following 
palliative  treatment  should  be  instituted : 

In  delayed  cases,  where  the  destruction  of  tissue  is  extensive,  the  local  applica- 
tion of  enzymol  and  pancreatis  ^  will  in  large  measure  arrest  putrefaction,  diminish 
the  discharge,  and  greatly  lessen  the  offensive  odor.  In  the  author's  experience, 
pancreatis,  to  which  an  equal  part  of  water  is  added,  applied  on  absorbent  cotton 
twice  daily  directly  to  the  surface  of  the  ulcer  is  preferable.  Enzymol  may  be 
substituted  in  the  same  dilution  and  applied  in  the  same  way  every  third  day. 
The  foot  of  the  bed  should  be  well  elevated  for  tv;o  hours  after  each  application. 
In  the  cases  subjected  to  this  treatment,  the  area  of  inflammation  which  circum- 
scribes the  epitheliomatous  infiltration  has  in  every  instance  been  markedly  less- 
ened together  with  the  pain,  which  is  due  in  large  measure  to  infection. 

Cancer  of  the  body  of  the  uterus  is  usually  located  in  the  fundus  near  the 

cornu.     One  of  the  earliest  symptoms  of  deep-seated  carcinoma  is  an  irritating 

discharge,    which    gradually    increases    in    quantity.      While   not    accompanied   by 

marked  bleeding,  as  in  cancer  of  the  cervical  portion  of  the  uterus,  this  discharge 

1  Fail-child  Brothers  &  Foster. 


630  THE   GENITO-URINARY   ORGANS   IN   FEMALES 

is  apt  to  be  streaked  with  blood.    It  also  carries  with  it  evidences  of  putrefaction, 
as  shown  by  the  disagreeable  odor. 

Pain  is  more  apt  to  be  present  in  a  cancer  situated  in  this  location  than  when 
the  cervix  is  involved. 

The  diagnosis  is  extremely  difficult  and  cannot  positively  be  determined  unless 
a  thorough  curettage  is  done,  and  a  careful  microscopical  examination  made  of 
the  tissues  removed. 

The  treatment  demanded  is  an  immediate  removal  of  the  uterus  with  the 
adnexa,  and  in  this  operation  the  suprapubic  route  is  to  be  jDreferred. 

Sarcoma  of  the  uterus  is  comparatively  rare.  It  is  exceedingly  difficult  to 
differentiate  this  neoplasm  from  myoma,  although  in  general  the  sarcomatous  tu- 
mors grow  more  rapidly  than  uterine  fibroids.  The  ovary  is  occasionally  the  seat 
of  sarcoma. 

The  surgical  treatment  is  an  immediate  removal  of  the  organ  involved  with 
the  adnexa.  As  with  sarcoma  in  anjr  other  portion  of  the  body,  the  prolonged 
injection  of  the  mixed  toxines  should  follow  the  operation. 

In  preparing  the  operative  field  for  aiclominal  hysterectomy,  especial  care  should 
be  given  to  cleansing  the  vagina  and  preventing  any  uterine  discharge  from 
escaping.  The  line  of  incision  and  the  technic  of  closing  the  wound  is  given  in 
the  chapter  on  Celiotomy. 

The  incision  should  at  first  be  large  enough  to  permit  the  introduction  of  two 
fingers  for  careful  exploration.     It  may  be  enlarged  upward  or  downward  to  any , 
extent  demanded  by  the  conditions  which  require  to  be  remedied. 

In  case  of  uterine  myoma,  single  or  multiple,  which  are  subperitoneal  or  pedun- 
culated, if  the  patient  be  within  the  child-bearing  period  carefid  consideration 
should  be  given  to  the  possibility  of  removing  these  from  the  wall  of  the  uterus 
with  the  smallest  possible  -detriment  to  the  function  of  this  organ. 

In  the  performance  of  this  operation,  the  peritonaeum  covering  the  attachment 
of  the  tumor  should  be  incised  and  carefulh^  reflected  with  the  curved  dull-pointed 
scissors  on  all  sides  down  to  and  slightly  beyond  the  attachment  to  the  uterine 
wall.  The  pedicle  or  base  of  the  tumor  should  then  be  excised  and  all  hsemorrhage 
stopped  by  the  insertion  of  sutures  of  strong  chromicized  catgut  (Nos.  2,  3,  or 
4,  as  may  be  required),  the  needle  being  so  inserted  as  to  occlude  all  bleeding 
points.  The  peritonasum  should  then  be  carefully  stitched  over  the  seat  of  the 
attachment  of  the  tumor,  leaving  a  perfectly  smooth  surface  which  will  not  invite 
adhesions. 

Should  there  be  a  large  vascular  tumor,  all  bleeding  can  be  absolutely  controlled 
by  surrounding  the  uterus  at  its  neck  with  a  strong  piece  of  rubber  tubing,  which 
is  temporarily  clamped,  to  be  removed  when  the  operation  has  been  completed. 

All  of  these  procedures  in  the  pelvis  are  simplified  by  a  partial  or  extreme 
Trendelenburg  posture.  If  the  tumor  fills  the  cavity  of  the  pelvis,  the  incision 
is  of  necessity  extended.  It  should  always  be  large  enough  to  enable  the  operator 
to  see  clearly  the  various  organs  and  to  lift  the  tumor  out  through  the  wound 
without  traumatism  to  the  intestines  and  other  contiguous  viscera. 

In  many  of  these  cases  adhesions  between  the  tumor  and  omentum,  mesentery 
or  the  intestines  have  occurred  which  should  be  carefully  separated,  tying  on  both 
sides  with  strong  catgut  all  masses  in  which  blood  vessels  are  observed. 

In  lifting  a  large  uterine  fibroid  from  the  pelvis,  it  is  frequently  easier  to  do 
this  by  grasping  it  with  strong  volsella,  since  it  may  be  difficult 'to  introduce  the 
hand  on  account  of  the  size  of  the  mass. 

The  most  important  points  to  bear  in  mind  in  hysterectoni}^,  especially  for  large 
fibroids,  is  the  relation  of  the  anterior  surface  of  the  uterus  to  the  bladder,  to  the 
antero-lateral  portions  where  the  ureters  are  under  normal  conditions,  and  to  the 
posterior  portion  in  its  relati.ons  to  the  rectum. 

The  safest  way  to  proceed  is  to  be  certain  that  the  l3ladder  has  been  thoroughly 
emptied,  and  in  all  doubtful  cases  to  ascertain  its  exact  relations  to  the  anterior 
surface  of  the  uterus  by  introducing  a  sound  into  the  bladder  the  point  of  which 
clearly  maps  out  the  summit  of  this  organ.  By  dividing  the  peritonseum  above 
this  plane,  and  keeping  close  to  the  body  of  the  uterus  and  the  cervix,  all  danger 


THE  GENITO-URINARY  ORGANS  IN  FEMALES  631 

to  the  bladder  and  ureters  may  be  avoided.  All  bleeding  points  encoiintered  should 
be  clamped  temporarily,  to  be  tied  when  the  tumor  has  been  removed.  The  same 
preca^ition  posteriorly  will  prevent  ^ny  possible  injury  to  the  rectum.  The  peri- 
toneal covering  may  also  be  wiped  off  with  a  gauze  swab.  In  the  early  part  of 
the  operation,  when  the  tumor  has  first  been  exposed  and  lifted,  the  broad  liga- 
ments should  be  carefully  clamped,  always  keeping  close  to  the  mass  in  order  to 
shun  the  ureters,  a  careful  lookout  for  which  should  be  kept.  Should  the  operator 
be  short  of  assistance,  it  would  be  a  wise  precaution  to  tie  at  once  the  larger  vessels, 
two  or  three  in  number,  which  occupy  each  broad  ligament. 

The  operation,  however,  may  be  more  expeditiously  performed  by  applying 
clamps  and  dividing  between  them,  first  removing  the  tumor  and  then  securing 
every  possible  source  of  hemorrhage.  This  may  be  done  either  by  ligature  en  masse 
with  strong  celluloiden  linen,  or  preferably  by  N"os.  2,  3,  or  4  ten-day  catgut  sutures 
carried  along  the  raw  edge  with  a  tight  button  stitch  tied  every  half  inch  or  so 
with  a  firm  knot,  continuing  the  suture  with  the  same  piece  of  gut. 

The  operator  should  be  aljsolutely  sure  that  every  source  of  bleeding  is  under 
assured  control  before  closing  the  wound.  When  the  uterus  shall  have  been  removed 
at  the  junction  of  the  cervix  with  the  vagina,  this  opening  should  be  closed  by  a 
row  of  catgut  sutures,  continuous  or  interrupted,  as  the  operator  may  prefer,  and 
then  the  peritoneum,  which  has  been  stripped  from  the  body  of  the  uterus,  should 
be  sewed  over  this  line  of  sutures  in  the  vagina  in  such  a  way  that  there  will  be 
no  raw  surfaces  for  the  adhesion  of  intestines. 

Ovariotomy. — Should  there  be  an  ovarian  tumor  present,  this  may  be  removed 
through  a  much  smaller  incision  than  that  required  in  hysterectomy  on  account 
of  myoma.  The  cystic  character  of  the  neoplasm,  if  not  determined  before  the 
incision,  will  be  easily  recognized,  and  its  liquid  contents  evacuated  through  a 
trocar  carefully  inserted,  the  ruljl^er  tube  attached  to  which  conveys  the  fluid  into 
a  basin  at  the  side  of  the  operating  table.  The  emptied  sac  can  now  easily  be 
drawn  through  the  incision  and  the  pedicle  of  the  tumor  tied  up  with  celluloiden 
linen.  Should  adhesions  be  preseiit  or  should  any  complication  arise,  the  incision 
may  be  extended  and,  if  necessary,  the  Trendelenburg  posture  assumed. 

In  the  suprapubic  operation  for  the  removal  of  septic  foci  in  the  pelvic  organs, 
as  in  gonorrhceal  salpingitis,  etc.,  the  same  incision  should  be  made  and  the  Tren- 
delenbvirg  posture  is  advised.  In  this  operation,  infection  being  presumable,  the 
first  precaution  is  to  see  that  all  intestinal  loops  are  carried  out  of  the  pelvis  and 
a  careful  dam  of  sterilized  gauze  inserted  in  such  a  manner  as  to  prevent  the  con- 
tact of  any  septic  matter  which  may  be  liberated  in  the  separation  of  adhesions 
from  the  peritonasum. 

All  liEemorrhage  should  be  thoroughly  controlled,  and  in  case  a  considerable 
quantity  of  purulent  fluid  is  encountered  the  question  of  drainage  by  an  opening 
through  Douglas'  cul-dc-sac  is  entitled  to  careful  consideration. 

In  chronic  or  subacute  cases  of  pyosalpinx,  it  is  rarely  necessary  to  take  this 
extreme  precaution,  but  where  there  are  evidences  of  recent  pelvic  peritonitis,  and 
T/here  the  resistance  of  the  patient  is  low,  it  is  advisable  to  lean  to  the  side  of 
caution  and  take  advantage  of  this  method  of  drainage,  closing  the  upper  wound 
as  in  a  clean  operation. 

When  an  intraligamentous  fibroid  is  encountered,  complete  hysterectomy  should 
be  done.  It  is  important  to  secure  the  large  vessels  distributed  to  the  ovaries  and 
broad  ligaments  as  the  first  step  in  the  operation.  The  ureters  are  frequently 
misplaced  by  being  carried  ovef  the  upper  limit  of  these  tumors  in  the  process 
of  their  development.  They  may  be  avoided  by  keeping  beneath  the  peritoneal 
covering  of  the  broad  ligaments.  It  is  safer  to  ligate  the  ovarian  and  uterine 
vessels  separately  rather  than  to  tie  them  en  masse. 

When  in  these  operations  any  portion  of  the  cervix  is  left,  the  canal  should  be 
thoroughly  curetted  and  a  short  catgut  drain  inserted  in  the  os. 

Hysterotomy  and  Abdominal  Hysterectomy. — Hysterotomy,  or  cutting  into  the 
uterus  for  the  extraction  of  the  fcetus  from  the  living  mother,  is  an  operation 
which  has  been  greatly  perfected  within  the  last  few  years,  chiefly  owing  to  the 
labors  of  Saenger,  Leopold,  and  Tait.    It  is  indicated  when  at  full  term  it  is  found 


632 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


impossible,  on  account  of  insnrmoiintable  disproportion  between  the  diameters  of 
the  pelvic  outlet  and  the  child,  to  effect  delivery  by  the  vagina,  and  when  sym- 
physeotomy will  not  give  sufficient  outlet  for  instrumental  delivery.  When  this 
condition  is  evident,  proceed  as  rapidly  as  possible  in  the  following  manner: 

If  the  membranes  are  not  already  ruptured,  break  them.  Disinfect  the  vagina 
and  genitals  with  sublimate  solution,  1-3000.  Prepare  the  abdomen  as  for  an 
ovariotomy,  and  make  a  long  abdominal  incision,  controlling  all  bleeding  with  cat- 
gut ligatures  as  the  operation  proceeds.  Having  entered  the  abdominal  cavity  and 
made  the  opening  large  enough,  place  three  or  four  silk  sutures  at  the  upper  end 
of  the  wound  in  order  to  narrow  the  opening  as  soon  as  the  uterus  is  drawn  out 
of  the  incision,  thus  avoiding  extrusion  of  the  intestines.  Drag  the  uterus  outside 
the  abdominal  cavity,  and  close  the  upper  portion  of  the  wound  by  tightening  the 
sutures  already  in  position.  If  the  intestines  should  be  protruded,  protect  them 
Avith  warm  torrels  wrung  out  of  sterile  salt  solution,  and  beneath  the  uterus  pass 
sterile  gauze  mats  or  towels  to  protect  the  abdominal  cavity  from  the  entrance  of 
blood.  Around  the  cervix  uteri  pass  a  stout  piece  of  elastic  tubing,  and  draw  it 
tight,  thus  arresting  the  circulation  in  the  uterus.  Immediately  incise  the  uterus 
in  the  median  line  and  in  its  long  axes,  limiting  the  incision  below  to  the  peri- 
toneal reflection,  thus  avoiding  the  large  circular  sinuses  about  the  os  internum, 
and  extending  it  upward  if  necessary.  Eemove  the  child,  and  hand  it  to  an  assist- 
tant  to  resuscitate.  The  uterus  will  now  usually  contract.  Introduce  the  hand 
into  the  uterus  and  remove  the  placenta.  The  uterine  cavity  is  next  to  be  dried 
out  with  gauze.  Unless  the  cervical  canal  is  widely  dilated  (and  this  should  be 
ascertained  before  the  operation),  the  use  of  a  utero-vaginal  drainage-tube  is  indi- 
cated, and  this  latter  must  be  of  stiff  rubber  or  glass.  The  next  step  in  the  opera- 
tion is  the  insertion  of  the  sutures  in  the  wall  of  the  uterus.  First  ascertain 
whether  the  peritoneal  covering  of  this  organ  is  sufficiently  movable  to  allow  it 
to  be  folded  in  between  the  sides  of  the  incision.     If  need  be,  dissect  it  up  from 


Fig.  638. — Sutures  m  Caesaie  ui  -section  Method  of  passing  Hil  sutuii  s  in  tlosing  the  wall  of  the  uterus 
after  hysterotomy  a.  The  peritoneal  covering  dissected  up  along  the  edge  of  the  incision  and  in- 
verted by  the  catgut  suture,  after  the  method  of  Lembert.  b,  The  muscular  substance,  with  the 
silver-wire  suture  passed  through,     c,  Decidua.      (Drawn  by  Dr.  W.  R.  Pryor.) 

its  attachment  to  the  muscular  fibers  a  slight  distance  and  fold  it  in  between  the 
lips  of  the  wound.  The  deep  sutures  of  celluloiden  linen  are  passed  as  shown  in 
Fig.  638.  They  should  be  close  enough  to  control  hsemorrhage  and  secure  accurate 
adjustment  of  the  sides  of  the  wound.  They  should  enter  the  peritoneal  covering 
about  half  an  inch  from  the  edge  of  the  wound,  and  pass  through  it  and  the  mus- 
cular wall  to  the  decidua,  which  must  not  be  included  in  the  suture;  then  across 
to  the  other  side  through  the  muscular  and  serous  coats.  To  secure  perfect  coap- 
tation of  the  serous  edges  of  the  incision,  ten-day  catgut  is  employed.  They  are 
introduced  in  the  same  way  as  Lembert's  suture  of  the  intestine. 

The  incision  in  the  abdominal  wall  is  closed,  as  after  ovariotomy.  There  are 
certain  conditions  which  can  only  be  determined  by  inspection  through  the  incision 
in  the  abdominal  wall  which  may  contra-indicate  the  operation  jitst  given,  and 
necessitate  a  modified  procedure. 

If  the  patient  has  been  long  in  labor,  and  considerable  time  has  elapsed  after 
the  membranes  have  ruptured;  if  there  is  a  putrid  discharge  from  the  vagina;  if 


THE   GENITO-URINARY   ORGANS   IN  FEMALES  633 

the  symptoms  of  septic  fever  are  present,  with  the  perimetrium  dulled  and  adherent 
to  the  muscular  wall  of  the  uterus,  the  operation  of  amputation  of  the  uterus  at 
the  OS  internum  may  be  indicated.  If  malignant  disease  of  the  cervix  is  present, 
the  entire  organ  should  be  removed.  If  the  pregnant  uterus  be  the  seat  of  a  fibro- 
myoma,  and  so  situated  as  to  render  delivery  impossible,  or  if  a  rupture  of  the 
walls  of  the  uterus  has  occurred,  which  is  so  ragged  in  outline  that  it  cannot  be 
sutured,  hysterectomy  is  indicated.  The  objects  aimed  at  in  all  operations  for  the 
artificial  delivery  of  children  at  term  are  preservation  of  the  mother's  life  and 
future  health,  with,  if  possible,  the  non-mutilation  of  her  generative  organs  and 
the  delivery  of  a  living  child.  ^ 

Hysterectomy  during  Pregnancy. — Porro's  operation,  which  is  more  often  fatal 
than  hysterotonw,  is  sometimes  called  for  in  the  removal  of  an  infected  uterus  at 
the  same  time  that  the  delivery  is  effected  by  hysterotomy.  In  performing  this 
operation,  an  abdominal  incision  is  made  similar  to  the  one  just  described.  As 
the  bladder  is  usually  high  up  in  these  eases,  and  in  good  j)art  uncovered  by  peri- 
tonjeum,  care  nuist  be  taken  that  the  incision  does  not  wound  this  organ.  As  soon 
as  the  litems  is  exposed  it  should  be  drawn  out  of  the  abdominal  cavity.  A  strong 
rubber  ligature  is  now  thrown  around  the  uterus  at  the  cervix.  The  intestines 
should  be  protected  by  sterile  mats  or  warm  towels,  which  have  been  boiled.  These 
should  also  be  placed  underneath  the  uterus,  in  order  to  protect  the  peritoneal 
cavity  from  the  entrance  of  blood  or  infectious  material.  As  soon  as  the  rubber 
ligature  is  seciirely  tightened  around  the  cervix  the  uterus  should  be  rapidly  incised 
and  the  child  extracted  at  once.  A  linear  incision  is  preferable.  The  uterus  should 
now  be  divided  as  close  to  the  rubber  ligature  as  possible,  and  ligatures  applied 
through  the  broad  ligaments  on  each  side  to  cut  off  all  vascular  supply  to  the  stump 
of  the  cervix,  which  should  then  he  excised.  A  careful  toilet  of  the  pelvic  cavity 
should  be  made,  after  which  it  should  be  packed  with  a  ribbon  of  iodoform  gauze 
introduced  either  through  the  abdominal  incision  from  above  or  through  an  in- 
cision in  Douglas'  cul-de-sac,  and  the  abdominal  wound  should  be  closed.  The 
iodoform  gauze  should  be  withdrawn  through  .the  vaginal  opening  five  or  six  days 
after  the  operation.  It  is  very  essential  in  this  operation  that  the  vagina  be  ren- 
dered as  aseptic  as  possible.  It  should  also  be  repacked  with  iodoform  gauze  when 
the  dressing  is  changed.  When  the  gauze  is  removed  from  Douglas'  cul-de-sac 
a  second  and  much  smaller  packing  should  be  reinserted. 

Symphyseotomy.— This  operation,  which  consists  in  the  division  of  the  car- 
tilage between  the  two  pubic  bones  in  the  median  line  at  the  symphj^sis,  is  indi- 
cated in  a  certain  proportion  of  cases  which,  by  abnormal  narrowing  of  the  pelvic 
outlet,  would  otherwise  be  subjected  to  the  more  formidable  operation  of  abdominal 
hysterectomy  or  to  cephalotripsy. 

The  operation  may  be  performed  subcutaneously  or  by  the  open  incision.  E.  A. 
Ayers'  method  is  as  follows :  After  shaving  the  parts,  under  thorough  asepsis, 
secure  full  dilatation  of  the  cervix  if  possible  without  risk  to  the  child.  The 
patient  is  brought  to  the  edge  of  the  table  and  placed  in  the  lithotomy  position. 
A  small  male  urethral  sound  is  introduced  into  the  bladder,  and  with  it  the  ure- 
thra and  lower  portion  of  the  bladder  are  held  firmly  to  the  patient's  left  side. 
The  labia  minora  and  clitoris  are  then  drawn  well  up  and  also  to  the  patient's 
left.  The  operator  introduces  the  left  index-finger  into  the  vagina,  and  carries 
this  along  the  posterior  curve  of  the  symphysis  to  the  top  of  the  joint  in  the 
median  line.  A  small  incision  is  now  made  about  one  half  inch  below  the  clitoris. 
A  curved,  probe-pointed  bistoury  is  passed  into  this  wound  close  against  the  joint 
to  the  top  of  the  symphysis,  until  the  probe  point  is  felt  against  the  end  of  the 
left  index-finger,  which  is  behind  the  bone.  The  cutting  edge  of  the  blade  is  turned 
downward,  the  back  of  the  knife  being  toward  the  vessels  of  the  clitoris.  The 
bistoury  is  now  worked  carefully  down  through  the  cartilage  of  the  symphysis. 
The  success  of  the  division  is  determined  by  the  separation  which  ensues,  the  left 
finger  being  able  to  appreciate  the  space  between  the  bones  as  they  are  separated. 
In  dividing  the  subpubic  ligament  it  is  advisable  to  change  the  direction  of  the 

'  As  regards  statistics,  Saenger  gives  thirty  Csesarean  sections  performed  as  above  described, 
with  a  mortality  of  26.7  per  cent. 


634 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


bistoury  and  cut  up  instead  of  down.  In  Dr.  Aj^ers'  cases  the  separation  varied 
from  two  to  two  and  a  half  inches,  enabling  the  easy  delivery  of  the  child  by  the 
application  of  forceps.  If  for  any  reason  the  operator  may  not  feel  justified  in 
attempting  the  subcutaneous  operation,  separation  can  readily  and  with  perfect 
propriety  be  secured  through  an  open  wound  made  above  the  genital  apparatus, 
exposing  the  symj)hysis  pubis,  hj  a  modification  of  the  incision  given  for  supra- 
pubic cystotomy. 

Vaginal  Hysterectomy. — In  this  operation  the  patient  rests  upon  the  back,  with 
the  thighs  and  legs  flexed  well  upon  the  abdomen,  in  which  position  they  should 
be  steadily  held  by  an  assistant  or  by  strapping  to  the  table. 

The  Trendelenburg  posture,  the  body  of  the  patient  being  prevented  from  slip- 
ping by  shoulder  supports  attached  to  the  table,  is  advised.    Pryor's  portable  oper- 


FlG.  639. — Prol.  \\  .  R.  Pijur^  upurating  Iramc  folded  for  transportation. 


ating  table  (Figs.  639,  640),  to  which  these  shoulder  supports  may  be  attached, 
will  be  found  very  satisfactory.  A  careful  toilet  of  the  vaginal  cavity  is  essential, 
and  the  usual  intra  vaginal  scrubbing  with  soap,  brush,  and  sterile  water  should 
be  followed  by  the  application  of  1-1000  mercuric-chloride  solution,  the  excess  of 
which  is  washed  out  by  hot  salt  solution.  To  prevent  the  possibility  of  any  septic 
matter  escaping  from  the  uterine  cavity,  a  plug  of  sterile  gauze  should  be  tightly 
inserted  in  the  cervical  canal. 


Fig.  640. — The  same  in  position  for  ordinary  uses. 


Lateral  retraction  with  the  right-angle  spatula?  will  expose  the  cervix,  which 
should  be  seized  by  a  strong,  doul^le  volsella,  fastened  into  both  lips  and  strong 
traction  made,  dragging  the  uterus  well  into  the  vulvo-vaginal  outlet. 


THE   GENITO-URINARY   ORGANS   IN   FEMALES 


635 


-  When  the  conditions  -will  permit,  in  order  to  keep  as  far  away  from  the  base 
of  the  bladder  and  the  ureters  as  possible,  the  separation  of  the  vaginal  attachment 
to  the  cervix  should  be  made  by  keeping  as  close  to  the  substance  of  the  neck  and 
body  of  the  uterus.  The  same  precaution  on  the  posterior  aspect  of  the  uterus 
will  preclude  the  jDossibility  of  wounding  the  rectum. 

In  malignant  disease,  where  the  infiltration  has  extended  to  the  vagina,  this 
cannot  well  be  done,  and  the  incision  here  must  of  necessity  be  well  away  from 
the  limit  of  induration. 

The  instrument  which  will  be  found  most  generally  useful  is  the  short,  curved 
scissors,  which  may  be  either  dull-  or  sharp-pointed,  preferably  the  former.  As 
the  dissection  proceeds  on  the  anterior  surface  of  the  body  of  the  uterus,  when  the 
tissues  begin  to  yield  readily  the  dull-pointed  scissors  may  be  pushed  along  the  an- 


FiG.  C41. — AppUcatiou  of  Pryor's  lock  forceps. 


terior  wall  of  the  uterus  into  the  peritoneal  cavity  and  the  opening  enlarged  by 
forcibly  separating  the  handles;  or  the  index-finger  may  be  used  for  this  purpose. 

As  soon  as  the  jDcritonseum  has  been  entered  on  the  anterior  surface  of  the 
uterus,  the  dissection  should  be  carried  laterally  on  each  side  around  the  cervix, 
but  not  higher  than  one  half  inch  for  fear  of  cutting  the  uterine  artery. 

As  soon  as  the  peritoneal  cavity  is  entered  posteriorly  through  Douglas'  cul- 
de-sac,  the  operator  should  introduce  the  index-finger  in  order  to'  determine  the 
presence  of  adhesions  either  to  intestinal  loops  or  to  other  organs. 

The  next  step  in  the  operation  is  the  application  of  Pryor's  lock  forceps.  These 
instruments  are  so  constructed  that  they  may  be  clamped  in  position  and  the 
handles  removed,  thus  taking  away  much  of  the  weight  and  the  sense  of  dragging 
and  discomfort  which  was  caused  by  the  earlier,  heavier  forceps.  The  first  pair 
is  apjjlied  on  one  side  of  the  cervix,  keeping  close  to  the  body  of  the  uterus  in 
order  to  prevent  including  the  ureter  in  the  clamp   (Fig.  641). 

A  second  clamp  is  applied  in  the  same  line  as  the  first,  but  the  point  is  directed 


636  THE   GENITO-URINARY   ORGANS   IN   FEMALES 

a  little  farther  out.  This  second  clamp  is  intended  to  include  the  remainder  of 
the  broad  ligament  and  to  control  the  ovarian  artery  as  the  first  clamp  did  the 
uterine.     Some  operators  prefer  to  apply  these  clamps  from  above  downward. 

Both  sides  being  thus  securely  clamped,  the  broad  ligament  with  the  Fallopian 
tubes  on  either  side  is  divided  between  the  clamp  and  the  uterus,  and  this  organ 
removed.  There  should  be  no  hemorrhage,  and  any  oozing  which  may  have  oc- 
curred should  now  be  removed  with  gauze  swabs,  and  the  cavity  packed  with  plain 
sterile  gauze,  as  in  the  vaginal  operation  for  puerperal  sepsis.  This  should  be 
changed  on  the  fourth  or  fifth  day. 

The  clamps  should  be  removed  at  the  end  of  forty-eight  hours.  In  order  to 
guard  against  hagmorrhage,  the  jaws  should  be  slowly  and  carefully  separated  with- 
out dragging  upon  the  broad  ligaments. 

Wlien  in  an  emergency  vaginal  hysterectomy  is  deemed  necessary,  and  the  lock 
clamps  are  not  at  hand,  the  uterine  and  ovarian  arteries  and  other  portions  of  the 
broad  ligament  may  be  secured  by  strong  ligatures  of  celluloiden  linen.  When  these 
are  employed,  it  is  advisable  to  leave  the  ends  of  each  ligature  in  the  vagina  so 
that  they  may  be  removed  by  traction  after  occlusion  of  the  vessels  has  been 
accomplished.  This  precaution  is  taken  to  prevent  the  possibility  of  prolonged 
infection  or  abscess  which  occasionally  occurs  when  a  non-al)sorbable  ligature  has 
been  left  within  the  peritoneal  cavity  after  vaginal  hysterectomy. 

Tumors  of  the  Parovarium  and  Ovary 

Parovarian  cyst  originates  in  the  remains  of  the  parovarium  between  the  layers 
of  the  broad  ligament.  In  its  growth  it  usually  forces  the  uterus  to  one  side,  be- 
coming intimately  attached  to  this  organ.  In  very  rare  instances  a  parovarian  cyst 
will  break  through  one  of  the  layers  of  t.lie  broad  ligament  and  become  peduncu- 
lated. As  a  rule,  however,  the  attachment  of  their  base  is  broad.  The  Fallopian 
tube  and  ovary  will  usually  be  found  on  top  of  the  tumor.  The  ureter  is  forced 
out  of  its  normal  position,  and  appears  on  the  anterior  surface  of  the  mass.  The 
growth  of  a  parovarian  cyst  is  slow.  The  early  symptoms  are  those  of  pressure  on 
the  other  viscera.  A  careful  examination  will  detect  a  soft  tumor  situated  close 
to  the  side  of  the  uterus,  and  not  very  movable. 

Treatment. — The  high  025eration  is  preferable.  The  ovarian  vessels  are  ligated 
near  the  cornua  of  the  uterus,  and  an  incision  is  made  through  one  layer  of  the 
broad  ligament,  which  should  be  bluntly  dissected  over  the  summit  of  the  tumor. 

If  vessels  of  any  size  are  encountered,  they  should  be  caught  with  the  forceps 
and  tied  at  once.  If  isolated,  a  strong  chromicized  catgut  will  suffice;  but  when 
portions  of  the  ligament  or  other  tissues  are  included  (ligature  en  masse),  linen 
is  the  safer  material.  There  is  almost  always  considerable  oozing  after  the  removal 
of  a  broad  ligament  cyst  which  may  necessitate  a  cul-de-sac  piack  and  temporary 
drainage. 

Ovarian  cysts  develop  chiefly  from  the  cortex  of  this  organ,  in  which  they  may 
remain  small  in  size  for  a  variable  period  and  then  rapidly  develop  into  large 
tumors,  at  times  almost  completely  filling  the  abdominal  cavity.  They  are  filled 
with  fluid,  which  varies  in  color  from  a  yellow  to  a  dark  green,  usually  of  thick 
consistency  and  high  specific  gravity.  This  fluid  is  furnished  by  the  epithelial 
lining  of  the  cyst  wall. 

Diagnosis. — If  the  tumor  is  in  the  pelvis,  it  is  nearly  always  found  behind  the 
uterus.  In  its  growth  it  lifts  the  uterus  forward,  and  is  apt  to  produce  pressure 
symptoms  in  the  bladder.  This  form  of  tumor  is  usually  pedunculated,  easily 
movable,  and  not  painful.  When  large  enough  to  occupy  the  abdominal  cavity,  it 
may  at  times  be  mistaken  for  abdominal  dropsy.  It  may  be  difEerentiated  from 
this  condition  from  the  fact  that  the  fluid  in  ascites  changes  its  level  with  the 
position  of  the  patient. 

Treatment. — The  operative  jDrocedure  has  already  been  given. 

Dermoid  cysts  of  the  ovary  contain  hair.  Jjone,  teeth,  and  other  rudimentary 
tissues.  The  tumor  is  usually  small,  with  a  thick  wall  and  of  firm  consistency. 
They  are  apt  to  cause  considerable  pain,  and  if  neglected  or  overlooked  may  ruji- 


THE   GENITO-URINARY   ORGANS   IN   FEMALES  637 

ture  and  cause  peritonitis.  They  slionld  be  removed  as  soon  as  recognized,  and 
in  case  of  rupture  an  immediate  operation  is  imperative. 

Ectopic  gestation  maj-  take  place  in  tliat  portion  of  the  Fallopian  tube  within 
the  uterus  (interstitial)  or  in  the  free  portion  of  the  tube  (tubal)  or  beginning 
in  the  tube,  it  may  escape  between  the  folds  of  the  broad  ligament  (intraligamen- 
tous pregnancy).  In  rare  instances  it  is  located  between  the  tube  and  the  ovary, 
or  it  may  escape  into  the  abdominal  cavity.  Occasionally  an  interstitial  pregnancy 
ma}'  become  freed  from  its  original  attachment  and  escape  into  the  uterus. 

Symptoms. — The  patient  may  liave  all  the  signs  of  uterine  pregnancy,  or  they 
may  be  entirely  absent.  Amenorrhosa  is  present  in  the  larger  proportion  of  cases. 
AVhen  rupture  of  the  tube  occurs  there  is  usually  a  sudden  and  very  sharp  sense 
of  pain,  often  followed  by  a  shock  and  collapse  due  to  a  more  or  less  profuse 
hasmorrhage. 

Should  infection  occur,  peritonitis  is  apt  to  develop  with  great  rapidity.  After 
rupture  the  destruction  of  the  foetus  is  inevitable,  and  operation  should  be  done 
at  the  earliest  possible  moment  in  the  effort  to  save  the  life  of  the  mother. 

Examination  in  tubal  pregnancy  will  reveal  a  mass  on  one  side  close  to  the 
uterus,  which  is  often  quite  sensitive  under  pressure. 

Treatment. — Celiotomy  should  be  performed  at  the  earliest  possible  moment 
after  the  presence  of  ectopic  pregnancy  is  recognized.  The  embr3'o  and  all  Ijlood 
clots  should  be  carefully  removed  and  a  thorougi  toilet  made,  instituting  cul-de-sac 
drainage  when  indicated. 


CHAPTEE   XXXII 

DEFOEMITIES 
DEFORMITIES  OF   THE  SPINAL  COLUMN 

Any  noticeable  deviation  from  the  normal  curvatures  of  the  vertebral  column 
constitutes  a  deformity.  They  are  congenital  and  acquired,  temporary  or  perma- 
nent. They  are  divisible  into  two  great  classes,  namely,  those  due  to  lesions  of 
the  column  (bones  or  cartilages),  and  those  due  to  lesions  of  the  soft  tissues 
(muscles  and  ligaments);  To  the  former  belong  dislocations,  fractures,  destructive 
ostitis,  and  spina  bifida;  to  the  latter,  muscular  torticollis,  lateral  or  rotary-lateral 
curvature  (scoliosis),  stoop-shoulder  (cyphosis),  curvature  from  pleuritic  adhe- 
sions, collapse  of  the  lung,  contractions  of  cicatrices  follovsring  burns,  scalds, 
phlegmon,  etc. 

Lateral  and  Rotary-lateral  Curvature. — Simple  lateral  curvature  of  the  spine — 
that  is,  a  bowing  to  one  side  without  rotation  of  the  vertebrae — is  extremely  rare. 
It  may  occur  in  any  portion  of  the  column  to  a  slight  extent,  although  rotation  is 
very  apt  to  take  place  with  the  curvature.  It  is  more  often  observed  in  the  cervical 
region  than  elsewhere,  and  is  known  as  torticonis,  or  "  wry-nech." 

The  causes  of  wry-neck  are — 1,  loss  of  parallelism,  or  balance  of  power  between 
opposing  muscles,  and  2,  cicatricial  conditions. 

Muscidar  torticollis  is  by  far  the  most  frequent  form,  and,  in  common  with 
all  deformities  resulting  from  lesions  of  the  muscles,  the  right  side  is  usually 
affected.  The  right  sterno-mastoideus  muscle  is  the  principal  seat  of  tonic  spasm, 
or  there  is  partial  or  complete  paralysis  of  the  same  muscle  of  the  left  side,  causing 
this  organ  to  stand  out  in  relief;  the  right  ear  is  drawn  down  toward  the  clavicle 
of  that  side,  while  the  chin  points  well  to  the  left  (Fig.  642).  The  trapezius  not 
unfrequently  is  contracted  with  the  mastoid  muscle.  The  splenius,  scaleni,  pla- 
tysma  myoides,  or  levator-anguli  scapulae,  are  less  frequently  involved.  Loss  of 
equilibrium  between  the  muscles  of  the  two  sides  occurs  chiefly  in  chlorotic  pa- 
tients in  whom  the  normal  muscular  tone  is  greatly  diminished,  rendering  the 
organ  of  the  left  (or  non-preferred)  side  unable  to  resist  the  more  developed  mus- 
cles of  the  right  half  of  the  body.  In  other  cases  the  lesion  may  be  situated  in 
the  central  nervous  ganglia,  or  in  the  track  of  the  nerve. 

Inflammation  of  the  muscular  substance  (myositis),  or  of  the  tendons  or  sheaths 
of  the  muscles,  is  an  occasional  cause  of  wry-neck.  Any  inflammatory  process  may 
lead  to  shortening  of  the  muscles,  and  to  contractions  in  the  fasciaj  and  connective 
tissues  of  the  neck.  Muscular  torticollis  is  met  with  most  frequently  in  the  j'oung, 
may  exist  at  birth,  is  seen  in  females  oftener  than  males,  and  in  this  class  of  cases 
is  apt  to  occur  about  the  age  of  puberty.  In  some  instances,  in  addition  to  the 
tonic  spasm  of  the  muscles  involved,  a  clonic  or  irregular  convulsive  movement 
occurs. 

Diagnosis. — The  recognition  of  torticollis  is  usually  free  from  difficulty.  The 
elimination  of  caries,  dislocation,  fracture,  and  ■nTV-neck  caused  by  cicatricial  con- 
tractions is  determined  from  the  history  of  the  case  and  by  inspection  and  manip- 
ulation. 

When  one  sterno-mastoid  muscle  is  contracted,  the  chin  is  pointed  to  the  oppo- 
site side,  and  the  occiput  made  to  approximate  the  clavicle  of  the  side  correspond- 
ing to  the  contracted  muscle.  The  splenius  capitis  draws  the  mastoid  process 
downward  and  backward  toward  the  spine  of  the  seventh  cervical  vertebra. 

The  prognosis  in  muscular  torticollis  is  usually  favorable — less  so  in  clonic 

638 


DEFORMITIES 


639 


than  in  tonic  muscular  spasm.     In  -n-ry-neck  due  to  contractions  of  the  fascite, 
tendons,  etc.,  the  deformity  is  with  diiBculty  relieved. 

Treatment. — Cldorosis,  or  any  dyscrasia,  should  be  treated  by  tonics  and  in- 
ternal medication,  by  properly  selected  diet  and  out-of-door  life.  The  develop- 
ment of  the  muscles  of  the  left  (or  weaker)  side  is  essential.  Kneading,  massage, 
and  electricity  will  be  found  useful  adjuvants.  Mechanical  appliances  should  be 
used  in  overcoming  the  contractions  in  the  offending  muscles.  Artificial  muscles, 
composed  of  elastic  bands  or  rubber  tubing,  more  nearly  fulfill  the  indications. 
The  origin  and  insertion  should  correspond  to  that  of  the  normal  muscle.  A 
thoracic  belt  or  jacket  of  plaster  of  Paris,  leather,  or  silicate  of  soda,  properly 
adjusted,  will  serve  for  the  points  of  fixation  of  the  lower  end  of  the  elastic 
material.  The  upper  insertion  near  the  occipiit  is  best  secured  by  a  stall  carried 
around  the  head  above  the  ears  and  across  the  forehead.  In  order  to  prevent  it 
from  slipping,  the  portion  which  rests  upon  the  skin  of  the  forehead  should  be 
made  of  strong  adhesive  plaster  (as  advised  by  Professor  Sa3Te).  ,  The  tension  on 
the  rubber  muscle  may  be  increased 
from  day  to  day,  if  necessary.  If  this 
method  does  not  succeed,  the  apparatus 
(Fig.  643)  should  be  tried.  The 
mechanism  is  well  shown  in  the  accom- 
panying cut,  the  correction  of  the 
deformity  being  effected  by  means  of 
a  series  of  joints  situated  at  the  back  of 
the  neck,  which  are  worked  by  a  key, 
and  can  be  fixed  at  any  angle  of 
flexion  and  rotation. 


Fig.  642. — Muscular  torticollis.     (.Alter  Sayre.) 


-Apparatus  for  the  correction  of  mus- 
cular torticollis. 


The  operative  procedures  include  stretching  or  division  of  the  muscle  or  mus- 
cles affected,  tenotomy,  neurectomy,  division  of  the  fascia,  and  the  free  dissection 
of  cicatricial  tissue.  Of  these  operations,  tenotomy  of  the  sterno-mastoideus  is 
most  frequently  demanded.  A  puncture  is  made  a  little  to  the  outer  side  of  the 
clavicular  tendon  of  this  muscle,  and  a  long,  probe-pointed  tenotome  slid  flatwise 
(the  cutting  edge  downward)  upon  the  outer  anterior  surface  of  the  clavicle.  As 
soon  as  the  point  of  the  instrument  has  passed  between  the  clavicular  and  sternal 
origins,  the  edge  is  turned  outward,  making  the  muscle  tense,  and  the  tendon  is 
divided  subcutaneously.  The  sternal  origin  is  divided  by  an  additional  puncture. 
After  tenotomy  the  prothetic  apparatus  should  be  employed  until  recovery  is  com- 
plete. In  dividing  the  body  of  this  muscle,  or  the  trapezius,  splenius,  or  levator- 
anguli  scapula3,  the  open  method  should  be  followed. 

Violent  and  sudden  stretching  of  the  muscles,  with  or  without  anffisthesia,  is 
not  advisable.  Exsection  of  that  portion  of  the  spinal  accessory  nerve  which  is 
supj)iied  to  the  sterno-mastoid  and  trapezius  muscles  is  occasionally  performed  in 


640 


DEFORMITIES 


order  to  jDaralyze  the  jjermanently  contracted  muscles'.  It  is  preferable  to  a  simple 
division  or  to'  stretching  of  the  nerre,  for  the  reason  that  a  divided  nerve  maj^ 
reunite,  and,  after  stretching,  the  function  of  the  nerve  is  only  temporarily  impaired. 

In  order  to  expose  this  nerve,  make  an  incision  about  four  inches  in  length, 
following  the  posterior  border  of  the  sterno-mastoideus  muscle,  and  commencing 
on  a  level  with  a  point  half-way  between  the  lobule  of  the  ear  and  the  angle  of  the 
jaw.  The  fibers  of  the  muscle  should  be  sought,  and,  recognizing  these,  the  pos- 
terior edge  is  exposed.  By  keeping  the  wound  dry,  and  working  close  to  the  under 
surface  of  the  muscle  the  vessels  will  be  avoided  and  the  nerve  will  be  seen  running 
obliquely  downward  and  outward,  and  passing  into  the  muscle.  One  or  two  super- 
ficial nerves  are  sometimes  seen  radiating  from  the  cervical  plexus.  From  one- 
half  to  one  inch  of  the  nerve  should  be  excised.  After  this  operation,  mechanical 
treatment  should  be  instituted  for  a  short  time. 

In  torticollis  due  to  cicatrices,  simple  division  of  the  contracting  tissue  affords 
only  temporary  benefit.  The  only  legitimate  method  is  to  dissect  out  the  offending 
tissue,  slide  sound  skin  over  the  wound  thus  made,  and  use  mechanical  treatment 
until  the  deformity  is  overcome. 

Deformities  due  to  dislocations  and  fractures  of  the  cervical  vertebrae  have  been 
considered,  and  those  resulting  from  caries  of  this  portion  of  the  spine  will  be 
given  hereafter. 

Lateral  and  Rotary-lateral  Curvature  of  the  Doiso-liimhar  Spine. — Simple  lat- 
eral curvature  of  the  dorso-lumbar  spine  is  exceedingly  rare.  It  is  complicated 
in  almost  ail  cases  by  rotation  of  the  vertebrae  upon  each  other,  and  in  deformity 
here  from  muscular  causes,  the  rotation  precedes  the  lateral  curvature. 

Lateral  curvature  is  usually  caused  by  an  inequality  in  the  length  of  the  lower 
extremities.     Fig.  644  was  taken  from  a  boy  in  whom  the  right  extremity  was  one 


and  a  half  inch  shorter  than  the  left.  With  both  soles  on  the  same  plane,  marked 
lateral  curvature  (convexity  to  the  right)  was  observed.  By  placing  the  foot  of 
the  short  side  upon  a  Ijook  of  the  required  thickness,  the  deformity  disappeared 
(Fig.  645). 

Inequality  in  the  length  of  the  lower  extremities  is  not  uncommon,  even  in 


DEFORMITIES 


641 


individuals  -n-ho  have  not  suffered  from  injury  or  disease.  A  difference  of  as  much 
as  one  inch  has  iDeen  noted,  ivhile  from  one  half  to  one  fourth  inch  is  quite  common. 
Cicatricial  contractions  on  one  side  of  the  chest  or  ahdomen,  as  after  extensive 
Inirns  or  in  chronic  pleuritic  adhesions  vrith  collapse  of  the  lung,  also  produce  this 
deformitv.     The  treatment  will  be  considered  with  that  of  rotarv-lateral  curvature. 


Pig.  646. — Lateral  cur\'ature  after  recovers'  from 
lumbo-sacral  spondylitis. 


Fig.   647. — Rotary-lateral   cuirature 
fifteen  years  of  age. 


a  girl 


Rotary-laterdl  Curvature. — Eolation  of  the  bodies  of  the  vertebrae  iipon  each 
other,  and  upon  the  sacrum  and  subsequent  or  simultaneous  lateral  curvature,  is 
one  of  the  most  difficult  deformities  to  correct.  The  chief  cause  is  loss  of  the 
normal  equilibrium  of  the  muscles  of  the  two  sides  of  the  trunk.  The  tendency 
to  deformity  is  increased  by  the  haljit  of  sitting  sidewise  at  the  table  or  desk,  with 
one  shoulder  drooping  while  the  other  is  elevated,  or  in  the  twisted  and  unnatural 
position  which  females  on  horseback  assume.  A  large  majority  of  those  affected 
are  chlorotic  girls,  between  thirteen  and  eighteen  years  of  age,  although  this  de- 
formity is  occasionally  met  with  in  muscular  and  healthy  porters  or  laborers  who 
habitually  carry  heavy  weights  upon  one  shoulder.  The  rotation  most  frequently 
commences  in  the  lumbar  region.  The  spines  are  pointed  to  the  right.  whUe  the 
anterior  aspect  of  the  bodies  of  the  vertebrse  are  made  to  look  toward  the  left. 
The  convexity  of  the  curve  is  to  the  left,  the  right  shoulder  is  prominent,  the  apes 
tilted  outward,  the  angles  of  the  ribs  on-  this  side  project  abnormally,  and  there 
is  a  foldins:  in  or  wrinkling  of  the  skin  between  the  iliac  crest  and  the  thorax 
(Fig.  64?  )T 

The  chief  agent  iu  this  distortion  is  believed  to  be  the  latissimus  dorsi  muscle. 
Acting  upon  the  tips  of  the  long  spines  of  the  litmbar  vertebras  from  its  insertion 
in  the  humerus  (and  indirectly  through  the  pectoralis  major,  from  the  clavicle 
and  sternum),  the  spines  are  twisted  to  the  right,  causing  the  rotation  of  the 
bodies  to  the  left ;  the  shoulder-blade  is  tilted  outward,  and  the  ribs  are  bent  imder 
the  contraction  of  this  long  and  comparatively  powerful  muscle. 

In  some  instances  the  abdominal  muscles  take  part  in  the  imilateral  contraction, 
while  in  others  the  deformity  commences  with  the  rotation  of  the  dorsal  vertebrfe 
by  the  action  of  the  serratus  magnus,  rhomboidei,  and  deep  short  muscles  of  the 


642 


DEFORMITIES 


back.  ISTo  matter,  where  the  primary  curve  takes  place,  a  second  or  compensatory- 
curve  follows  in  all  chronic  cases. 

The  diagnosis  of  rotary-lateral  curvature  will  depend  upon  the  prominence  of 
the  shoulder-blade,  bulging  of  the  ribs,  and  the  approximation  of  the  crest  of  the 
ilium  and  thorax  of  the  right  (or  affected)  side.  Caries  of  the  spine  may  be 
eliminated  by  the  absence  of  abnormal  temperature,  freedom  from  pain  when  direct 
pressure  is  made  from  the  head  along  the  vertebral  column,  and  absence  of  symp- 
toms of  compression  of  the  cord  or  nerves  in  the  intervertebral  notches.  Psoas 
abscess  is  present  in  a  certain  proportion  of  cases  of  ostitis  of  the  vertebrfe. 

In  simple  lateral  curvature  the  ribs  are  not  projected,  as  when  rotation  occurs, 
nor  is  the  tip  of  the  shoulder-blade  so  prominent. 

The  prognosis  varies  with  the  character  of  the  lesion.  In  recent  lateral  curva- 
ture, due  to  inequality  of  length  in  the  extremities,  it  is  favoralole.  In  rotary- 
lateral  curvature,  within  the  first  few  months  of  the  lesion,  a  cure  may  be  effected. 
In  old  cases,  while  the  deformity  may  be  arrested,  it  is  difficult  and  often  impos- 
sible to  restore  the  normal  contour  of  the  spine  and  ribs. 

Treatment. — When  the  lesion  is  due  to  loss  of  equilibrium  in  the  muscles  of 
the  two  sides,  especial  attention  should  be  directed  to  the  development  of  the  organs 
of  the  weaker  side,  and  at  times  it  is  necessary  to  impair  the  nutrition  of  the 
muscles  of  the  stronger  half  of  the  trunlc.  When  the  deformity  is  on  the  right 
side,  the  muscles  of  the  left  arm  and  side  should  be  exercised  by  the  use  of  the 
dumb-bells,  elastic  strap,  swing,  or  horizontal  bar.     It  is  often  advisable  to  place 


-Patient  lying  in  a  position  to  overcome  contraction  of  the  muscles  of  the  left  side  of  the 
abdomen  and  thorax.        (After  Reeves.) 


the  right  arm  and  hand  in  a  sling,  to  prevent  the  further  development  of  these 
muscles.  Massage  or  kneading,  confined  to  the  left  half  of  the  body,  and  the  gal- 
vanic current  to  the  same  region  two  or  three  times  a  week,  will  be  advisable. 
Tonics,  Judicious  feeding,  and  out-of-door  life  are  essential  features  of  treatment. 
The  patient  should  be  directed  to  sit  squarely  upon  the  buttocks,  and  not  to  droop 
or  loll  to  one  side.  In  reclining,  the  body  should  be  placed  in  such  a  position 
that  the  offending  muscles  are  put  upon  the  stretch  (Fig.  648).  The  deformity 
is  temporarily  overcome  by  the  employment  of  Wolff's  cradle  (Fig.  649).  The 
belt  passes  over  the  projecting  ribs  and  shoulder-blade,  thus  bringing  the  weight 
of  the  trunk  upon  these  parts,  while  gravity  aids  in  overcoming  the  curvature  in 
the  lumbar  region. 

In  a  certain  proportion  of  cases,  mechanical  support  of  the  thorax  is  indicated, 
especially  in  those  cases  where  from  muscular  weakness  it  is  almost  impossible  to 
hold  the  spine  erect.  For  this  purpose  the  plaster-of-Paris  jacket  or  the  perforated 
corset  may  be  used.  The  latter  (Figs.  650,  651)  I  have  found  very  satisfactory. 
It  is  to  be  commended,  for  the  reason  that  it  can  be  readily  removed  at  night,  and 
is  more  cleanly  than  a  permanent  plaster  jacket.  When  the  gypsum  is  applied  it 
should  be  split  down  the  front,  taken  off  and  fixed  for  lacing  so  that  it  may  be 
removed  when  necessary. 


DEFORMITIES 


643 


This  perforated  corset  is  made  as  follows:  A  plaster-of -Paris  jacket  is  applied 
as  hereafter  directed,  and  as  soon  as  this  hardens  (in  from  ten  to  thirty  minutes) 
it  is  split  dowTi  the  median  line  in  front,  removed  from  the  body,  and  the  cut 


-WolfE's  suspensory  cradle.     Patient  in  position  when  the  contraction  is  on  the  right  side 
(with  the  right  shoulder-blade  and  ribs  projecting).     (After  Reeves.) 


edges  placed  and  held  ia  apposition  by  a  bandage  carried  around  and  over  the 
entire  jacket.     This  shell  is  to  be  used  as  a  mold  in  which  a  cast  of  the  deformed 
thorax  is  to  be  made.     It  is  thorougMy  greased  on  its  inner  surface,  placed  upon 
the  floor,  and  filled  with  stiff  plaster 
mortar.     When  this  hardens,  the  shell 
is  removed,  leaving   an   exact   cast  of 
the  thorax,  upon  which  the  corset  is  to 
be  built. 


Fig.  650. — Corset  made  after  Vance's  method. 


Fig.  651. — The  same,  applied. 


The  materials  needed  are  white  glue,  ordinary  muslin  rollers,  flat  spring  steel 
about  one  eighth  of  an  inch  wide  and  very  thin,  and  one  yard  of  Canton  flannel. 
Place  the  flannel  with  the  soft  plush  next  to  the  plaster,"  and  stitch  this  tightly 
to  the  model,  so  that  it  is  not  wrinkled.  It  shoidd  be  sewed  only  along  the  middle 
line  in  front.  The  glue  should  now  be  dissolved  in  warm  water.  Strips  of  bandage 
about  two  feet  long  and  two  inches  iu  width  are  dipped  in  the  glue  and  laid  on 
the  flannel  which  is  around  the  model.  As  soon  as  a  single  thickness  has  been 
applied,  strips  of  the  steel  wire,  cut  not  quite  as  long  as  the  corset,  are  placed  one 
inch  apart  over  its  entire  surface,  and  held  in  place  by  a  string  wound  around  as 


644 


DEFORMITIES 


tlie)^  are  laid  on.  A  long,  dry  roller  is  next  carried  around  the  model  from  aljove 
downward,  and  drawn  so  tight  that  the  steel  springs  are  made  to  conform  exactly 
to  the  surface  of  the  corset".  Upon  this  two  additional  laj'ers  of  the  short  strips 
of  roller  dipped  in  glue  are  laid*.  The  corset  should  be  left  for  several  hours  in 
the  hot  sun,  or  by  a  fire,  until  it  is  thoroughly  dried.  It  is  then  split  down  the 
front,  removed,  and  the  edges  bound  with  chamois  skin.  Hooks  for  lacing  shotdd 
be  fastened  along  the  edges  in  front.  Perforations  may  be  made  between  the 
springs  with  a  wadding  punch.  This  apparatus,  when  properly  made,  fits  accu- 
rately about  the  body  in  the  most  favorable  position  for  the  correction  of  the 
deformity.  It  can  be  removed  at  night  upon  retiring,  and  for  bathing,  changes 
of  clothing,  massage,  and  electricity.  It  is  lighter  and  cleaner  than  the  plaster-of- 
Paris  jacket.  When  the  necessary  materials  cannot  be  had,  the  plaster  Jacket 
should  be  employed. 

Dr.  Kewton   Shaffer,  of  Kew  York,  recommends  the  apparatus  used  by  him 
in  a  large  experience,  and  shown  in  the  accompan3ang  cuts.     The  pelvic  band  and 


:>     -S 


Fig.  652.  —  Scoliosis  or  rotary-lateral  curvature.        Fig.  653.- 


-The  same,  with  Shaffer's  rotary-lateral 
curvature  apparatus  applied. 


straps  support  a  perpendicular  Ijar,  which  terminates  in  the  axilla  of  the  unaffected 
side,  and  from  this  l^ar  the  traction  force  is  exerted.  The  perforated  metal  shield 
presses  upon  the  angles  of  the  distorted  ribs   (Fig.  653). 

Operative  interference  in  muscular  scoliosis  is  rarely  called  for.  In  extreme 
cases,  when  the  latissimus  dorsi  of  one  side  is  greatly  shortened  and  increased  in 
development,  correction  of  the  curvature  may  be  expedited  by  the  subcutaneous 
division  of  this  muscle. 

When  lateral  or  rotary-lateral  curvature  of  the  spine  results  from  inequality 
in  the  length  of  the  lower  extremities,  the  first  indication  in  treatment  is  to  elevate 
the  shoe  of  the  short  side,  and  thus  bring  the  plane  of  the  iliac  crests  at  a  right 
angle  to  the  axis  of  the  vertebral  column.  If  the  deformity  is  not  entirely  cor- 
rected by  this  plan,  the  measures  jitst  detailed  should  be  also  employed. 

When  the  deformity  is  caused  l^y  superficial  cicatricial  contractions,  their  divi- 
sion is  essential.  In  pleuritic  adhesions,  with  collapse  of  the  lung,  the  treatment 
given  for  rotary-lateral  citrvature  due  to  muscular  asymmetry  should  be  adopted. 

Anterior  and  Posterior  Curvature  of  the  Spine. — Anterior  curvature,  or  "  stoop 
shoulder,"   usually  occurs   in  the   dorso-cervieal   regions;   occasionstlly   the   entire 


DEFORMITIES 


645 


column  is  involved.  It  may  be  caiised  b}' — 1,  partial  or  complete  paralysis  of  the 
erector  muscles  of  the  back;  2,  tonic  spasm  of  the  abdominal  muscles;  3,  from 
inadvertence,  as  in  the  habit  of  allowing  the  shoulders  to  droop  forward,  with  or 
without  the  carrying  of  burdens;  -l,  cicatricial  contractions  in  the  anterior  thoracic 
and  abdominal  regions:  5,  heredity. 

Complete  paralysis  of  the  muscles  of  the  back  is  exceedingly  rare.     Unilateral 
paresis  is  not  altogether  imcommon.    The  most  frequent  condition  is  one  of  general 

impairment  of  muscular  tone,  the  head 
and  upper  spine  gravitating  forward  as 
the  muscles  yield,  until  the  posterior 
ligaments  are  elongated  and  the  anterior 
margins  of  the  intervertebral  disks  nar- 
rowed liy  compression.  The  haljit  of 
carrying  a  heavy  burden  upon  one  shoul- 
der is  more  likely  to  induce  rotary-lateral 
curvature  than  cy pilosis.  The  indica- 
tions are  to  correct  the  deformity  by  the 
use  of  braces,  and  to  increase  the  tone  of 
the  muscles,  the  nutrition  of  which  is 
impaired. 


Fig.  654. — Shaffer's  apparatus  for  correcting 
scoliosis. 


-Xyrop's  spring  brace. 
(After  Reeves.) 


To  meet  the  former,  in  mild  cases  a  double  elastic  brace,  such  as  is  shown  in 
Fig.  655,  will  be  sufficient.  ^Massage,  electricity,  tonics,  and  out-of-door  life  are 
also  essential  features  of  treatment. 

Posterior  curvature  of  the  spine,  lordosis  or  "  sway-back,"'  is  far  le^s  frequent 
than  the  condition  just  described.  It  occurs  almost  always  in  the  lumbar  region. 
In  the  later  months  of  pregnancy  it  is  a  common  condition,  and  is  met  with  in 
individuals  with  unusual  development  of  the  stomach  and  abdominal  viscera,  or 
in  cases  of  chronic  abdominal  tumor   (fibroid,  etc.). 

Spondylitis. — Destructive  ostitis  of  the  vertebra,  commonly  known  as  Pott's 
disease,  occurs  usually  between  the  third  and  fifteenth  year  of  life.  In  exceptional 
instances  it  is  observed  prior  to  three  years  of  age,  while  not  more  than  one  fifth 
of  all  cases  occur  after  the  fifteenth  year.  It  is  therefore  eminently  a  disease  of 
the  growing  period,  when  rapid  nutritive  changes  are  taking  place  in  the  bones. 

Wlule  no  portion  of  the  spine  is  exempt,  the  disease  is  much  more  frequent  in 
the  dorsal  vertebrse.  which  are  involved  in  about  two  thirds  of  all  cases.  The 
lumbar  and  cervical  portions  of  the  column  are  about  equally  liable  to  destructive 
ostitis.  Occipito-cervical  disease  is  rare.  Ostitis  in  the  lower  cervical  region  is 
apt  to  involve  the  upper  dorsal  by  extension,  and  the  sarne  is  true  of  ostitis  of  the 
lower  dorsal  in  their  relation  to  the  lumbar  vertebrje.  Lumbo-sacral  disease  is  not 
altogether  uncommon.  Destructive  ostitis  of  the  spine  is  divided  into  occipito- 
cervical, cervical,  cervico-dorsal,  dorsal,  dorso-himhar,  lumbar,  and  lumbosacral, 
according  to  the  recognized  location  of  the  disease. 

Causes. — Tuberculous  infection  is  the  cause  of  Pott's  disease  in  a  large  majority 
of  cases.  The  bacillus  tuberculosis  is  especially  liable  to  attack  the  cancellous 
tissues  of  the  vertebrse,  which  bones,  tosether  with  the  sternum  and  ribs,  are  the 


646 


DEFORMITIES 


last  to  take  on  tlie  changes  of  adult  life.  In  the  pathology  of  ostitis  it  was  shown 
that  the  medulla  of  these  bones  remains  in  the  red  or  embryonic  condition  long 
after  the  marrow  of  other  bones  has  undergone  the  adult  or  yellow  change,  and 
that  consequently  they  are  for  a  prolonged  period  liable  to  accidents  consequent 
upon  rapid  nutritive  changes,  and  especially  to  capillary  rupture  and  extravasation. 
Although  a  fall  upon  the  feet  or  hands,  or  violent  flexion  of  the  spine,  or  a  blow 
upon  the  sternum  or  ribs,  or  a  penetrating  wound,  may  lead  to  destructive  ostitis, 
yet  destructive  inilammation  of  these  structures  as  a  result  of  traumatism  is  com- 
jDaratively  rare.  Carcinoma  and  sarcoma  of  the  vertebral  column  is  very  infre- 
quent. Destructive  ostitis  of  one  or  more  vertebraB  is  occasionally  caused  by  pres- 
sure from  aortic  aneurism. 

Clinically,  destructive  ostitis  is  met  with  in  two  forms — the  dry  and  the  sup- 
purative. The  latter  variety  is  more  common.  In  dry  ostitis  pyogenic  infection 
does  not  occur,  the  bone  cells  undergo  granular  metamorphosis,  and,  together  with 
the  inorganic  salts  of  this  tissue,  are  absorbed.  In  these  cases  the  breaking  down 
of  the  bodies  of  the  vertebra3,  to  the  extent  of  marked  deformity,  may  occur  with- 
out recognized  febrile  movement.  In  the  suppurative  form,  when  mixed  infection 
occurs,  the  destructive  process  is  more  rapid,  aiid  is  accomi^anied  by  the  formation 
of  a  variable  quantity  of  embryonic  tissue,  the  bone  breaks  down  in  bulk,  and 
particles  varying  in  size  appear  in  the  pus  which  results  from  the  inflammatory 
process.  The  earliest  pathological  change  in  such  cases  is  in  the  cancellous  tissue 
•of  the  body.     In  rarer  instances  the  lesion  commences  as  a-  s3'novitis  in  the  costo- 


'.V-.' 


^ 


Fig.  656. — Destructive  ostitis 
of  tlie  anterior  portion  of 
the  bodies  of  the  vertebrie. 
(After  Noble  Smith.) 


Fig.  657. — The  same  process 
in  tlie  posterior  portion  of 
tlie  bodies  of  the  vertebra;. 
(After  Noble  Smith.) 


Fig.  658.  —  Deformity  result- 
ing from  fracture  of  a 
vertebra.  (After  Noble 
Smith.) 


vertebral  or  interarticular  joints,  whence  the  disease  may  invade  the  intervertebral 
disks  and  bodies.  Primary  inflammation  of  the  intervertebral  fibro-cartilage  is 
believed  to  be  very  rare.  As  the  destructive  process  continues,  the  cancellous  tissue 
of  the  body,  and  chiefly  of  the  anterior  portions  of  the  column,  breaks  down 
(Fig.  656),  causing  abnormal  curvature,  with  sharp  projection  of  the  spinous 
processes.  The  angular  deformity  is  less  apt  to  be  present  when  the  disease  attacks 
the  posterior  portion  of  the  body,  where  the  superincinnbent  weight  in  great  part 
falls  upon  the  articular  processes   (Fig.  657). 

Symptoms. — The  clinical  history  of  Pott's  disease  may  be  divided  into  two 
stages :  The  first  stage  includes  all  the  phenomena  which  occur  up  to  the  time  when 
deformity  is  recognized;  the  second  stage  embraces  all  the  changes  met  with  after 
deformity.  The  usual  symptoms  of  the  first  stage  are  pain  and  muscular  rigidity, 
with  varying  exacerbations  of  temperature.  Pain  may  be  elicited  when  the  patient 
assumes  the  erect  posture,  by  direct  pressure  upon  the  spines  of  the  vertebrae  in-, 
volved,  and  by  concussion  of  the  column  transmitted  from  the  head  downward. 
When  the  bodies  alone  are  involved  (the  usual  condition)  it  may  be  lessened  or 


DEFORMITIES  647 

made  to  disappear  entirely  by  suspension  of  the  patient  from  a  portion  of  the 
column  above  the  lesion;  l}y  bending  the  spine  Ijackward,  thus  throwing  the  weight 
upon  the  healthy  articular  processes;  or  by  laying  the  patient  face  downward 
across  the  surgeon's  lap,  and  making  extension  by  separating  the  Imees. 

Muscular  rigidity  is  recognizable  in  a  majority  of  instances,  and  in  children 
may  be  observed  as  a  spnptom  of  pain,  when  the  presence  of  pain  is  denied.  Fix- 
ation of  the  dorsal  muscles  is  evident  in  the  stiff  and  unusual  manner  in  which 
the  back  is  held  as  the  patient  moves  about,  and  in  the  awkward  posture  assumed 
while  sitting  down.  If  directed  to  bend  the  vertebral  column,  as  in  stooping  to 
pick  up  something  from  the  floor,  the  movements  are  cautious  and  constrained, 
altogether  lacking  in  the  celerity  and  suppleness  which  are  seen  in  flexion  and 
extension  of  the  vertebral  column  in  health.  In  the  earlier  stages  pain  is  dull  and 
steady  in  character,  and  is  usually  local,  being  confined  to  the  neighborhood  of 
the  part  affected. 

Elevation  of  temperatiire  may  be  present  at  any  stage  of  Pott's  disease.  It  is, 
as  a  rule,  the  index  of  pyogenic  infection  with  inflammatory  and  destructive  proc- 
esses. The  thermometer  may  register  from  the' normal  as  high  as  101°-102°  F., 
and  only  in  exceptional  instances  as  high  as  10^°.  In  a  fair  proportion  of  cases 
in  the  early  stages,  and  esj^ecially  in  the  dry  form  of  ostitis,  no  elevation  of  tem- 
perature can  be  detected. 

The  second  stage  of  the  disease,  that  of  deformitj^,  may  be  present  in  the  course 
of  a  few  weeks  after  the  appearance  of  the  first  stage,  or  several  months  may 
elapse.  All  of  the  sjinptoms  of  the  preceding  stage  are  present  in  the  second  stage 
of  Pott's  disease.  If  proper  treatment  has  not  been  instituted,  interference  with 
the  fimctions  of  the  cord  at  and  below  the  seat  of  lesion,  or  of  the  nerves  which 
pass  out  between  the  diseased  vertebras,  is  apt  to  occur,  from  displacement  of  the 
bones  or  as  a  result  of  infiamniatorjr  products  pressing  upon  the  spinal  cord  and 
nerves.  Paralysis  of  motion  and  sensation,  in  a  varjdng  degree,  occurs  in  a  certain 
proportion  of  cases. 

Wlien  deformity  occurs  the  convexity  of  the  curve  is  posterior  in  about  ninety- 
five  per  cent  of  all  cases.  The  "  Imuckie  "  may  consist  of  a  single  spinous  process 
(Fig.  .656),  or  several  spines  may  project,  as  in  Fig.  658. 

The  degree  of  deform  it}^  depends  upon  the  location  of  the  disease,  its  extent, 
and  in  part  to  general  relaxation  of  the  erector  muscles.  It  is  greater  when  the 
lower  cervical  and  upper  dorsal  vertebra  are  involved  (Fig.  659).  The  formation 
of  pus  and  the  resulting  abscess  and  sinuses  belong  chiefly  to  the  last  stage  of 
ostitis  of  the  spine.  The  abscess  maj''  travel  along  the  psoas  muscle,  opening  near 
the  middle  of  the  groin  above  or  beneath  Pouixirt's  ligament,  the  pus  may  escape 
through  the  inguinal  canal,  over  the  iliac  crest,  or  through  the  sacro-sciatic  notch; 
or  it  may  be  arrested  at  a  higher  point  and  escape  recognition,  unless  careful 
examination  is  made  under  ether  narcosis. 

Spinal  abscess  is  usually  single,  occasionally  double.  When  occurring  in  the 
upper  dorsal  region  it  may  be  arrested  by  the  diaphragm,  or  jjass  behind  this  into 
the  sheath  or  fascia  of  the  psoas  muscle.  Abscess  in  ostitis  of  the  bodies  almost 
always  travels  downward  on  one  or  the  other  side  of  the  antero-lateral  aspect  of 
the  spine.  When  the  articular  processes  or  laminas  are  involved,  the  pus  may 
penetrate  the  dorsal  muscles  and  point  posteriorly. 

In  occipito-cervical  or  upper  cervical  spondylitis,  the  pus  collection  often  ap- 
pears at  the  posterior  wall  of  the  pharTOx  (retropharyngeal  ahscess).  Interference 
with  deglutition  and  phonation  is  not  infrequent.  The  contents  of  an  abscess 
resulting  from  destructive  ostitis  of  the  cervical  vertebrae  may  also  descend  along 
the  deep  fascia  of  the  neck  and  pass  into  the  thorax  or  the  mediastinum.  In  this 
manner  it  occasionally  finds  its  way  into  the  pericardium. 

Amyloid  changes  of  the  viscera  are  among  the  late  s^miptoms  of  chronic  spon- 
dylitis. 

Diagnosis. — In  general  the  recognition  of  the  disease  will  depend  upon  a  his- 
tory in  accordance  with  most  of  the  STOiptoms  just  detailed.  As  to  the  portion 
of  the  column  involved,  the  appreciation  of  localized  pain  by  direct  or  indirect 
pressure  is  an  indication  of  value.    Wlien  the  efferent  nerves  are  involved  by  pres- 


648  DEFORMITIES 

sure  from  the  products  of  inflammation,  certain  disturbances  in  their  course  or 
distribution  are  of  diagnostic  importance.  Spasm  of  the  larynx,  pharynx,  dia- 
phragm, pain  down  tire  arm,  etc.,  naturally  attract  attention  to  the  points  of  exit 
of  the  nerves  supplying  these  parts.  When  tenderness  in  the  region  of  the  psoas 
muscles  is  evidenced  by  habitual  indisposition  to  extend  the  thighs,  lumbar  ostitis 


\. 


Fig.  659. — Caries  of  the  bodies  of  the  third,  fourth,  and  fiftli  cervical  vertebrce. 

may  be  suspected.  When  the  gibbosity  is  recognized,  a  diagnosis  is  no  longer 
doubtful.  The  early  recognition  of  abscess  in  the  abdominal  region  is  possible 
only  by  palpation  under  profound  narcosis. 

If  the  articular  processes  are  diseased,  bending  of  the  spinal  column  backward 
will  increase  the  pain.  Placing  the  patient  on  the  abdomen,  with  the  head  and 
lower  extremities  depressed,  will  diminish  it.  When  the  bodies  and  interver- 
tebral disks  are  involved,  bending  the  spine  backward  will  reveal  the  pressure 
symptoms. 

Treatment. — In  the  mechanical  treatment  the  indications  are  to  secure  fixation 
of  the  spinal  column  in  the  position  of  least  discomfort  to  the  patient.  Judicious 
medication,  good  food,  and  jmre  air  are  the  indications  in  the  constitutional  treat- 
ment. The  character  of  the  mechanism  to  be  used  will  depend  in  good  part  upon 
the  portion  of  the  vertebral  column  involved.  It  is  essential,  in  order  that  any 
apparatus  may  fully  meet  the  indications,  that  not  only  shall  the  diseased  bones 
and  the  healthy  tissues  be  held  practically  immovable,  but  the  superincumbent 
weight  be  lifted.  Fixation  may  be  accomplished  by  any  form  of  well-adjusted 
apparatus,  but  lifting  the  weight  of  the  body,  wdiich  is  above  the  seat  of  disease, 
is  a  more  difficult  undertaking. 

The  downward  pressure  upon  the  bodies  ^vhen,  as  is  usual,  these  structures  are 
involved  and  breaking  down,  can  be  in  great  part  obviated  by  extension  or  back- 
ward bending  of  the  spine,  in  which  manoeuvre  the  pressure  is  transferred  from 
the  bodies  and  intervertebral  disks  to  the  articular  processes  and  pedicles. 

Much  of  the  apparatus  devised  for  the  arrest  and  cure  of  Pott's  disease  is  based 


DEFORMITIES  649 

upon  this  i^rinciple.  Another  method  is  based  upon  the  principle  of  lifting  the 
parts  above  the  seat  of  the  lesion,  and  removing  in  part  the  pressure,  not  only  from 
the  bodies  but  also  from  the  articular  processes  (extension  and  counter-extension, 
or  suspension). 

To  accomplish  the  former  the  spinal  braces  of  Drs.  Davis,  Taylor,  and  Shaffer 
have  been  constructed.  For  complete  extension  or  lifting,  the  plaster-of-Paris 
jacket  or  the  jury-mast  of  Professor  Sayre,  and  the  suspension  carriage  of  Dr. 
Meigs  Case,  more  nearly  meet  all  the  indications. 

In  appropriate  cases  each  of  these  forms  of  apparatus,  if  property  adjusted  and 
intelligently  worn,  will  accomplish  all  that  is  possible  in  the  mechanical  treatment 
of  Pott's  disease.  Much  of  the  discredit  which  is  brought  upon  any  particular 
apparatus  can  justly  be  charged  to  the  lack  of  judgment  in  the  selection  of  cases, 
want  of  skill  in  the  adjustment  of  the  instrument,  and  failure  on  the  part  of  the 
attendant  or  patient  in  persisting  in  its  use  a  sufficient  length  of  time. 

The  selection  of  the  apparatus  best  adapted  to  succeed  will  depend  upon  the 
location  of  the  disease  and  the  age  and  conformation  of  the  patient.  Clinically  the 
spinal  column  is  divisible  into  three  regions:  1,  embracing  the  occipito-cervical 
articulation,  the  cervical  vertebrs,  and  down  to  the  third  dorsal;  3,  from  the  third 
to  the  tenth  dorsal;  3,  from  the  tenth  dorsal  to  the  sacro-lumbar  articulation. 

The  lower  region  is  more  amenable  to  treatment,  the  upper  next,  while  the 
middle  region,  which  is  most  frequently  involved  in  ostitis,  is  the  most  diiScult 
to  manage. 

Third  Region. — In  the  mechanical  treatment  of  Pott's  disease  in  the  third 
region,  Sayre's  plaster-of-Paris  jacket,  of  light  make  and  properly  adjusted,  will 
give  great  satisfaction.     In  its  application  the  following  articles  are  essential: 

1,  A  suspension  apparatus;  2,  a  tight-fitting,  seamless,  knit  shirt;  3,  plaster- 
of-Paris  bandages.    The  suspension  apparatus  (Fig.  660)  consists  of  an  iron  cross- 


FiG.  660. — Suspension  apparatus  for  applj'ing  plaster-of-Paris  jacket.      (After  Sayre.) 


bar  from  which  are  suspended  padded  loops  for  each  axilla,  and  a  chin  and  occiput 
swing  for  lifting  from  these  points.  The  crossbar  is  attached  at  its  center  to  a 
block  and  pulley.  After  the  knit  shirt  is  ap])lied,  the  arms  of  the  patient  are 
slipped  through  the  padded  loops  while  the  collar  is  buckled  around  beneath  the 
chin  and  occiput.  The  center  and  lateral  suspension  straps  should  be  adjusted  so 
that  when  the  lift  is  made  the  tension  will  be  equally  distributed.  The  block  of 
the  pulley  apparatus  may  be  fastened  to  a  hook  in  the  ceiling  or  to  the  tripod 


650 


DEFORMITIES 


(Pig.  661).  The  plaster  bandages — the  method  of  preparing  which  is  given  on 
page  29 — should  be  perfectl}'  fresh  and  well  made,  for  a  good  deal  of  success 
depends  upon  the  qualitj'  of  the  gj'psum  and  the  thoroughness  with  which  it  is 
worked  into  the  mes'hes  of  the  crinoline.     As  the  direction  for  appljdng  this  jacket. 


Fig.  661. — Suspension  apparatus  and  trii:)od  in  position  for  lifting.     (After  Sayre.) 

as  given  by  Professor  Sayre — to  whom  the  profession  is  indebted  for  bringing  it  so 
prominently  into  use — cannot  be  improved  upon,  I  give  it  in  his  language: 

"  Before  applying  the  plaster  bandage,  I  place  over  the  abdomen,  between  the 
shirt  and  the  skin,  a  pad  composed  of  a  towel  folded  up  so  as  to  form  a  wedge- 
shaped  mass,  the  thin  edge  being  directed  downward.  This  is  intended  to  leave 
room,  when  removed,  for  the  expansion  of  the  abdomen  after  meals,  and  so  I  call 
it  the  '  dinner  pad.'  It  is  important  to  make  it  thin  where  it  comes  under  the 
lower  edge  of  the  jacket,  or  else  the  jacket  would  fit  too  loosely  about  the  lower 
part  of  the  abdomen.  It  should  be  taken  out  just  before  the  plaster  sets.  It  is 
always  a  good  j^lan  to  get  the  patient  to  eat  a  hearty  meal  before  the  jacket 
is  applied,  but  this  precaution  of  allowing  room  for  meals  should  never  be 
neglected. 

"  If  there  are  any  very  prominent  spinous  processes  which,  at  the  same  time, 
may  have  become  inflamed  in  consequence  of  pressure  produced  by  instruments 
previously  worn,  or  from  lying  in  bed,  such  places  should  be  guarded  by  little  pads 
of  cotton  or  cloth,  or  little  glove  fingers  filled  with  wool  placed  on  either  side  of 
them.  Another  detail,  which  I  have  found  to  be  of  practical  value  in  some  cases, 
is  the  apjDlication  under  the  shirt,  over  each  anterior  iliac  spine,  of  two  or  three 
thicknesses  of  folded  cloth  three  or  four  inches  in  length.     If  these  little  pads  be 


DEFORMITIES 


651 


removed  just  before  the  plaster  has  completely  set^  such  bony  processes  will  be  left 
free  from  pressure. 

"If  the  patient  be  a  female,  and  especially  if  she  be  developiag  at  the  time, 
it  vrUl  be  necessary  to  apply  a  pad  under  the  shirt  over  each  breast  before  the 
plaster  bandage  is  put  on.  These  pads  should  be  removed  just  before  the  plaster 
sets,  and  at  the  same  time  slight  pressure  should  be  made  over  the  sternum  for 
the  purpose  of  indenting  the  central  portion  of  the  plaster  jacket,  and  of  thus 
giving  form  to  the  body,  and  of  removing  pressure  from  the  breasts. 

"  The  skin-fitting  shirt  having  been  tied  over  the  shoulders,  and  then  pulled 
down,  and  kept  stretched  l^y  means  of  tapes  applied,  one  in  front,  the  other  behind, 
near  its  lower  edge,  and  tied  tightly  over  a  handkerchief  placed  on  the  perinaaum, 
the  patient  is  to  be  gently  and  slowly  drawn  up  by  means  of  the  apparatus  until  he 
feels  perfectly  comfortable,  and  «<?(■(??•  hetjond  iliat  point,  and  while  he  is  retained 
in  this  position  the  plaster  bandage  is  to  be  applied.  A  prepared  and  saturated 
roller,  which  has  been  gently  squeezed  to  remove  all  surjilus  water,  is  now  applied 
around  the  smallest  part  of  the  body,  and  is  carried  around  and  around  the  trunk 
downward  to  the  crest  of  the  iliuni,  and  a  little  beyond  it,  and  afterward  from 
below  upward  in  a  spiral  direction,  until  the  entire  trunk  from  the  pelvis  to  the 
axillgs  has  been  incased.    The  bandage  should  he  placed  smoothly  around  the  body. 


Fig.  661a. — Saj-re's  extension  as  emploj-ed  on  Do-n-ne5-'s  table. 


not  drawn  too  tight,  and  especial  care  taken  not  to  have  any  single  turn  of  the 
bandage  tighter  than  the  rest.  Each  layer  of  bandage  should  be  rubbed  most  thor- 
oughly with  the  hand  by  an  assistant,  that  the  plaster  may  be  closely  incorporated 
in  "the  meshes  of  the  crinoline,  and  liind  together  the  various  bandages  which  make 
up  the  jacket,  thus  making  it  much  stronger  than  if  attention  is  not  paid  to  this 
particular.     If  you  notice  "any  spot  which  seems  weak  or  likely  to  give  way,  pass 


(352  DEFORMITIES 

the  bandage  over  it,  and  then  fold  it  back  on  itself,  and  do  this  until  you  have 
placed  several  thicknesses  of  bandage  over  this  point,  being  careful  to  wet  all  well 
together,  and  then  pass  a  turn  completely  around  the  trunk  to  retain  any  ends 
which  might  have  a  tendency  to  become  detached. 

"  In  a  very  short  time  the  plaster  sets  with  sufficient  firmness,  so  that  the 
patient  can  be  removed  from  the  suspending  apparatus,  and  laid  upon  his  face 
or  back  on  a  hair  mattress,  or — what  is  preferable,  especially  when  there  is  much 
projection  of  the  spinous  processes  or  sternum — an  air  bed.  Before  the  plaster 
has  completely  set,  the  dinner  pad  is  to  be  removed,  and  the  plaster  gently  pressed 
in  with  the  hand  in  front  of  each  iliac  spinous  process,  for  the  purpose  of  widening 
the  jacket  over  the  bony  projections.  In  the  case  of  a  young  child  with  a  small 
pelvis  it  may  happen  that  the  circumference  of  the  body  at  the  umbilicus  is  as 
great  as  around  the  pelvis,  but,  as  the  soft  parts  in  the  lumbar  region  allow  us  to 
mold  the  plaster  as  we  choose,  you  can  still  obtain  a  point  of  support  at  the  pelvis; 
if,  as  the  jacket  hardens,  you  will  press  it  in  at  the  sides  above  the  ilium,  and  in 
front  and  rear  above  the  jDubes,  the  antero-posterior  diameter  above  will  be  the 
longer,  while  below  it  v/ill  be  the  transverse  one." 

When  the  angular  projection  is  extreme,  or  when  an  ulcer  exists,  it  will  be 
advisable  to  cut  a  hole  in  the  jacket  at  this  point  large  enough  to  prevent  any 
undue  jiressure.  In  case  of  abscess,  a  window  of  sufficient  size  to  allow  free  drain- 
age, and  a  frequent  change  of  dressing,  should  be  made. 

The  commendable  features  of  this  plan  of  treatment  are  the  extension  obtained 
by  suspension,  fixation  Ijy  the  ijlaster  while  in  the  most  favorable  position,  and  the 
cheapness  and  readiness  with  which  it  may  be  employed. 

The  objections  are,  uncleanliness  by  reason  of  the  immovable  nature  of  the 
apparatus,  and  the  excoriations  which  are  a  cause  of  considerable  complaint.  The 
first  objection  may  be  met  by  splitting  the  corset  down  in  front  and  reapplying 
it  each  time  while  the  patient  is  suspended,  and  making  it  tight  by  a  roller  car- 
ried around  the  body  several  times ;  or  a  row  of  hooks  may  be  fastened  on  either 
side  of  the  line  of  section  and  corset-lacing  used  to  hold  the  jacket  closely  ad- 
justed. As  for  excoriations,  it  ma}'  be  said  that  no  apparatus  which  grasps  the 
body  tight  enough  to  secure  fixation  is  free  from  this  danger.  When  they  occur 
with  the  plaster  jacket,  the  fault  generally  lies  either  in  the  improper  manner  of 
its  a23plication  or  carelessness  on  the  part  of  the  attendant. 

Second  Begion. — When  the  middle  or  dorsal  region  is  involved,  the  plaster 
jacket  is  not  so  serviceable  as  in  ostitis  of  the  vertebrae  in  the  lower  region  of  the 
spine,  although  much  good  will  be  accomplished  by  the  partial  fixation  of  the 
thorax  as  high  as  to  the  level  of  the  axilla.  The  efficacy  of  this  method  diminishes 
the  higher  the  diseased  process  is  located,  and,  when  the  lesion  invades  the  sixth 
dorsal,  or  above  this  point,  the  jacket  without  head  suspension  is  almost  useless. 
In  all  cases  of  Pott's  disease  above  the  tenth  dorsal,  suspension  of  the  head  or 
elevation  of  the  chin  is  an  essential  feature  of  treatment.  A  favorable  result  would 
be  achieved  in  a  greater  proportion  of  eases  if  this  point  were  insisted  upon,  and 
the  prejudice  against  the  suspension  apfiaratus  or  chin-lift  overcome. 

In  the  application  of  the  jury-mast  the  patient  should  be  suspended  as  just 
described,  and  a  plaster  jacket  applied  from  just  above  the  trochanters  up  as  high 
as  the  axillte.  After  two  layers  of  the  plaster  bandages  have  been  applied,  the 
jury-mast  is  adjusted,  and  its  framework  covered  in  with  the  succeeding  layers 
of  bandage.  The  jury-mast  (Tig.  662)  consists  of  a  back  piece,  in  shape  not 
unlike  the  inverted  letter  U,  made  of  soft  iron,  which  enables  it  to  Ijo  accurately 
molded  to  fit  the  surface  to  which  it  is  applied.  To  this  are  fastened  two  or  three 
strips  of  tin,  made  rough  by  a  series  of  perforations  with  an  awl.  To  the  upper 
end  of  the  back  piece  a  curved  bar  of  light  steel  is  attached,  in  such  a  manner 
that  it  can  be  raised  or  depressed  at  will.  At  the  end  of  this  crane  is  a  light  cross- 
bar, hooked  at  each  extremity,  from  which  the  collar  is  suspended.  After  the  first 
two  layers  of  plaster  bandages  have  hardened,  the  apparatus  is  bent  to  fit  the 
surface  of  the  back,  and  is  adjusted  to  the  jacket,  with  the  middle  piece  or  crane 
exactly  in  the  median  line  of  the  back  of  the  neck  and  occiput,  and  its  extremity 
over  the  center  of  the  top  of  the  head,  so  that  traction  by  the  strips  will  be  directly 


DEFORMITIES 


653 


upward.  It  is  fastened  by  carrying  plaster  rollers  over  the  tin  strips  and  Ijack 
piece,  and  working  in  plaster  mortar.  When  the  plaster  hardens,  the  apparatus 
is  immovably  incorporated  into  the  Jacket.  The  suspension  collar  should  now  l^e 
buckled  beneath  the  occipital  |)Totuberance,  and  the  strips  tightened  enough  to 
lift  the  weight  of  the  head  from  the  neck.  The  jacket  may  be  converted  into  a 
movable  corset  by  splitting  it  along  the  middle  line  in  front  and  attaching  hooks 
for  lacing  (Fig.  662a).  If  the  jury-mast  cannot  be  applied  in  ostitis  involving 
the  vertebrae  between  the  third  and 
ninth  dorsal,  Shaffer's  modification  of 
Taylor's  lu-ace  should  be  preferred. 


ITiG.  602. — Sayre's  jury-mast  head-swing. 
(After  Sayre.) 


Fig.  662a. — Jury-mast  apparatus  applied. 
(After  Sayre.) 


"  The  patient  is  placed  prone  upon  two  tables  of  equal  height,  and  the  tallies 
are  then  separated  so  that  the  diseased  area  may  be  freely  accessible  from  all  sides. 
One  assistant  grasps  the  patient  under  the  axil'lje,  the  other  makes  steady  but  easy 
traction  at  the  thighs.  While  the  patient  is  in  this  prone  j^osition  the  operator 
fits  the  uprights  to  the  line  of  the  transverse  processes;  in  other  words,  adjusts 
the  apparatus  to  the  deformity.  A  pair  of  '  monkey-wrenches '  may  be  easily  used 
as  a  pair  of  levers  with  which  to  bend  the  annealed  steel  uprights  into  any  shape. 
It  takes  but  a  few  moments  to  adapt  the  uprights  to  the  deformity.  The  traction 
is  affording  relief,  and  is  not  producing  any  injury.  Then  the  apparatus  is  laid 
on  the  laack  accurately,  traction  is  steadily  maintained,  and  the  thoracic  and  pelvic 
straps  are  fastened.  When  the  operation  is  complete,  the  jDatient  is  firmly  secured 
in  an  apparatus  which  affords  a  support  that  can  he  maintained  by  the  thoracic, 
axillary,  and  pelvic  straps,  and  the  uprights  are  held,  without  undue  pressure,  in 
their  position  by  the  circular  straps  and  bands."  ^ 

The  value  of  this  apparatus  consists  in  the  fair  degree  of  fixation  which  it 
secures,  but  chiefly  in  the  fact  that,  when  properly  applied,  the  dorsal  spine  is 
extended,  that  is,  bent  backward  to  such  a  degree  that  the  weight  from  above  is  re- 
moved from  the  diseased  bodies  and  transferred  to  the  sound  articular  processes 
and  pedicles.  If  this  position  is  j^roperly  maintained,  relief  will  usually  follow  in 
those  cases  where  the  bodies  alone  are  involved.  The  chin-rest  or  elevator  (Fig. 
664)  may  be  attached  to  this  same  apparatus. 

First  Eegion. — In  ostitis  of  the  vertebral  column,  from  the  third  dorsal  to  the 
occipito-atloid  articulation,  the  treatment  should  be  l)y  suspension  from  the  chin 
and  occiput,  or  by  tilting  or  lifting  the  chin  upward.     In  accomplishing  this  end 

I  "Pott's  Disease,"  etc.,  N.  M.  Shaffer,  M.D.     G.  P.  Putnam's  Sons,  New  York,  1879. 


654 


DEFORMITIES 


the  jury-mast,  or  chin-rest,  applied  and  worn  as  just  described,  will  meet  the  indi- 
cations. Much  good  may  be  obtained  from  the  judicious  use  of  extension  in  the 
recumbent  posture  (Fig.  665).  This  apparatus  may  be  worn  at  night,  when  the 
head  stall  of  the  jury-mast,  or  chin-lift,  is  removed.  In  the  worst  class  of  cases 
it  is  advisable  to  employ  the  extension  in  bed  until  the  s3fmptoms  of  paralysis  are  re- 
lieved. Instead  of  the  block  and  pid- 
ley,  with  weight,  the  extension  may 
be  made  by  elastic  bands  attached  to 


-Shaffer's  modification  of  Taylor's  spinal 
brace. 


Fig.  664. — Shaffer's  head  and  chin  support 
added  to  Taylor's  brace. 


the  chin-and-occiput  collar,  chin-piece,  and  the  head  of  the  bed,  while,  if  necessary, 
fixation  may  be  secured  by  elevating  the  head  of  the  bed  six  or  eight  inches. 

The  suspension  carriage  of  Dr.  Meigs  Case,  which  lifts  from  the  axilla,  chin, 
and  occiput  (Fig.  666),  is  a  valuable  apparatus  in  the  treatment  of  Pott's  disease 
in  the  cervical  and  upper  dorsal  region.  If  the  degree  of  elastic  suspension  from 
the  chin  and  occiput  which  it  affords  during  the  waking  hours  is  continued  during 


Fig.  665. — Extension  in  the  recumbent  posture.     (After  Reeves.) 

sleep,  by  the  method  of  extension  in  the  recumbent  posture  above  given,  success 
will  be  achieved  in  the  majority  of  cases.  It  is  chiefly  objectionable  by  reason 
of  its  high  price,  which  places  it  beyond  the  reach  of  many  who  can  obtain  the 
jury-mast. 

As  to  the  value  of  the  various  mechanical  devices.  Professor  Gibney  concludes 
"  that  in  very  young  children,  from  two  to  five  years,  the  wire  cuirass  with  a  good 
rest  for  the  head  and  means  for  making  moderate  traction,  such  as  the  swing  in 


DEFORMITIES 


655 


the  jury-mast,  is  an  excellent  apparatus.  In  older  children  some  modification 
of  the  Taylor  chin-piece  or  the  Whitman  chin-rest  attached  to  a  plaster-of-Paris 
jacket  or  corset  should  be  employed.  For  the  practitioner  remote  from  a  large 
city,  and  with  no  good  instrument  maker  at  hand,  nothing  is  cjuite  so  good  as  the 
plaster-of-Paris  jacket  with  the  jury-mast." 

The  successful  management  of  Pott's  disease  depends  not  only  upon  a  thorough 
practical  knowledge  of  the  construction  and  application  of  the  mechanical  appara- 


FiG.  666. — Dr.  Meigs  Case's  suspension  carriage,  for  both  the  standing  and  sitting  postures. 


tus  required,  but  upon  the  careful  and  constant  attention  of  a  competent  surgeon 
during  the  entire  time,  from  the  incipiency  of  the  spond3ditis  until  several  months 
have  elapsed  after  consolidation  is  effectecl.  The  prevention  of  chafing  and  sores, 
the  renewal  or  tightening  of  the  apparatus,  require  almost  as  much  skill  as  in  the 
diagnosis  and  first  adjustment  of  the  mechanism.  As  regards  abscess  in  ostitis 
of  the  vertebral  column,  it  may  be  said  that  incision  and  drainage,  as  shown  by 
Dr.  Shaffer,  are  not  indicated  unless  pyogenic  infection  of  the  tuberculous  abscess 
has  occurred.  Pain,  high  temperature,  and  other  symptoms  of  septic  absorption 
will  indicate  infection.  Fresh  air,  well-selected  articles  of  food,  and  tonics  are 
essential.  In  the  severer  cases,  in  which  a  myelitis  is  developed  from  compression 
by  the  products  of  inflammation,  potassium  iodide,  in  full  and  continued  doses,  is 


656 


DEFORMITIES 


recommended  b}'  Professor  Gilme}^  lu  all  cases  "n-liere  the  recumbent  posture 
is  assumed,  an  effort  should  be  made  to  keep  the  patient  on  the  liack,  with  a  pillow 
so  arrang-ed  that  the  spinal  column  is  bent  well  backward,  and  the  pressure  on  the 
bodies  in  this  way  partially  relieved.  The  suspensory  cradle  of  Eeeves  will  accom- 
plish this  end  more  successfully.    A  splint  or  shell  is  made  of  gutta-percha  or  sole- 


r^ 


Fig.  666a. — Reeves'  suspensory  cradle.      (After  Reeves.) 

leather,  and  molded  accurately  to  the  back,  from  the  sacrum  to  the  neck.  With 
this  held  in  position  by  a  roller,  the  patient,  while  lying  down,  is  supported  by  the 
swing,  as  shown  in  Fig.  666a. 


Dei-'Okmities   of  the   Loatee  Extremity 

The  deformities  of  the  lower  extremity  ma}'  be  divided  into  those — 1,  of  the 
coxo-femoral  region;  2,  of  the  shaft  of  the  femur  in  its  entirety;  3,  of  the  con- 
dyles; 4,  of  the  tibia  and  fibula;  5,  of  the  tarsus  and  metatarsus;  and,  6,  of  the 
phalanges. 

In  this  classification,'  distortions  of  the  pelvis,  such  as  in  malaeosteon  and 
rachitis,  are  excluded,  since  they  concern  the  obstetrician  rather  than  the  surgeon. 

At  the  Jiip  there  may  exist  preternatiiral  mobility,  or  partial  or  complete  im- 
mobilitjf  with  malposition.  Preternatural  mobility  may  be  due  to  the  following 
caiises :  Arrest  of  cleveloiiment  in  the  bones  which  form  the  acetabulum ;  congenital 
failure  of  development  of  the  head  of  the  femur,  or  atrophy  of  this  portion;  to 
both  of  these  conditions  combined;  abnormal  length  of  the  capsular  ligament,  and 
absence  of  the  ligamentum  teres.  In  a  majority  of  these  cases  of  congenital  dis- 
location the  abnormally  small  and  misshapen  head  of  the  humerus  is  found  near 
the  normal  site  of  the  rim  of  the  acetaljulum,  which  latter  is  rudimentary  and 
often  filled  with  fibrous  tissue. 

Immobility  with  malposition  results  from  inflammation  of  the  joint  and  anky- 
losis, with  or  without  destructive  ostitis  and  loss  of  substance.  Contraction  of  the 
psoas  and  iliacus  or  other  muscles  about  the  hip  which  are  not  overcome  before 
ankylosis  ensues  is  the  chief  cause  of  deformity.  Dislocation  with  failure  at  re- 
duction always  induces  deformity,  and  the  same  is  true  of  fracture. 

In  preternatural  mobility  at  the  hip-joint  (congenital  dislocation)  the  symp- 
toms are  chiefly  a  peculiar  rolling  gait,  or  oscillation  to  right  and  left  in  the  act 
of  walking,  especially  when  the  deformity  is  bilateral.  While  standing  erect,  the 
trochanters  will  be  closer  to  the  iliac  crest  than  normal,  which  condition  can  be 
accurately  determined  by  Xelaton's  or  Bryant's  test.  In  these  cases  the  anterior 
convexity  of  the  curve  in  the  lumbar  region  is  exaggerated,  giving  the  patient  a 
sway-back  appearance.  If  extension  is  made  from  the  feet,  ■«'hile  the  trunk  is 
fixed  in  the  recumbent  posture,  the  length  of  the  patient  will  be  considerably 
increased  over  that  measured  in  the  erect  position.  Aljsence  of  the  head  of  the 
femur  may  be  determined  by  palpation  with  outward  rotation  and  by  the  X-ray. 
Perforation  of  the  acetalDulum  may  also  be  made  out  by  digital  exploration  per 
rectnm. 

Treatment. — Congenital  dislocation  at  the  hi])  may  be  successfully  treated  by 
the  method  of  Lorenz  or  Allis.  'Under  anaesthesia,  Lorenz,  with  counter-extension 
by  means  of  a  sheet  in  the  periuKum,  moves  the  thigh  freely  in  all  directions, 
gradually  increasing  the  force  employed  until  every  structure  that  resists  reduc- 
tion is  hrohen  down.     Such  is  the  range  of  enforced  movement  that  the  toe  with 


DEFORMITIES 


657 


the  leg  extended  is  made  to  touch  the  ear,  then  hyperdistended  to  the  extreme 
limit  of  safety.  When  the  deformity  is  recognized  in  infancy  and  early  treatment 
instituted,  this  degree  of  violence  is  unnecessary. 

When  resistance  is  overcome  and  reduction  is  announced  hy  the  sudden  passage 
of  the  head  of  the  femur  from  an  outward  to  an  inward  position,  the  thigh  is 
flexed  and  ahducted  almost  to  the  horizontal,  while  the  pelvis  and  thigh  are  now 
enveloped  in  cotton  and  encased  ill  plaster  of  Paris.  In  order  to  do  this,  the 
sacrum  rests  ujjon  a  specially  devised  support.  The  bodj'  and  the  thigh  must  be 
held  steady  in  the  proper  position  while  the  plaster  hardens.  It  is  then  cut  away 
from  the  peruifeum  and  over  the  abdomen,  in  order  to  provide  for  cleanliness  and 
to  allow  for  abdominal  distention.  It  is  retained  without  change  for  five  or  six 
months,  the  child  walking  all  the  time  upon  the  deformed  member,  hammering 
the  caput  femoris  as  much  as  possible  into  the  acetabulum.  It  is  this  constant 
pounding  and  pressure  of  the  weight  of  the  bod}'  upon  the  thigh  in  the  new  posi- 
tion which  eilects  a  deepening  of  the  acetabulum  and  permits  the  ligaments  and 
muscles  to  contract  and  hold  it  permanent!}'  in  the  newly  made  socket.  In  apply- 
ing the  plaster  of  Paris  between  the  first  layer  of  ordinary  bandage-rollers  and 
the  back  and  abdomen  of  the  child,  long  strips  of  cotton-flannel  bandage  material 
should  be  laid,  the  ends  being  left  out  above  and  below.  As  the  plaster  remains 
on  such  a  length  of  time,  these  bandage  strips  are  used  as  "  scratchers,"  and  may 
be  moved  up  and  do'mi  over  the  loose  epidermis,  in  order  to  cleanse  the  skin. 

Allis'  method  is  as  follows: 

"  After  full  antesthesia  the  pelvis  of  the  child  is  firmly  secured  to  the  table  by 
means  of  bandages  and  hooks  placed  at  the  perinseum   and  sides   of  the  pelvis 


(Fig.  667).     To  prevent  the  bandages  from  interfering  with  the  free  maniptdation 
of  the  hips,  they  are  passed  over  a  bent  piece  of  iron  as  represented  in  Fig.  668. 


658  DEFORMITIES 

After  securing  the  pelvis  to  the  table,  angle  irons  (Fig.  667  D)  are  secured  to 
the  thigh  and  leg;  this  done,  vertical  traction  through  a  lever  is  made  (Fig.  667, 
ABC)  for  the  length  of  time  deemed  desirable.  With  the  spring  balance  {E) 
between  the  short  arm  of  the  lever  and  the  angle  irons  attached  to  the  limb,  the 
exact  amount  of  traction  can  be  seen.  Traction  from  twenty  to  thirty  pounds 
may  be  made  for  from  fifteen  minutes  to  half  an  hour,  after  which  the  lever  is 
detached  and  an  effort  made  to  replace  the  dislocated  femur.  This  is  done  by 
seizing  the  thigh  with  the  right  hand,  and  lifting  it  upward  until  the  head  of  the 
femur  is  on  a  level  with  the  socket,  and  then  making  abduction  against  the  thumb 
of  the  left  hand,  pressing  against  the  great  trochanter.  The  ease  with  which 
reduction  is  often  accomplished,  the  entire  absence  of  shock,  the  favorable  condi- 
tion the  following  day,  all  contrast  strongly  with  the  conditions  I  had  witnessed 
in  the  reductions  effected  by  Professor  Lorenz.  In  the  apparatus  used,  the  long 
fulcrum  (C  C  C,  Fig.  667),  whose  base  is  near  the  pelvis,  and  which  is  parallel 
with  the  femur,  permits  of  every  motion  that  is  desired  in  applying  traction.  Thus 
one  is  able  to  lift  perpendicularly,  abduct,  adduct,  flex,  extend,  circumduct,  and 
rotate,  all  the  time  gently  increasing  the  traction  with  a  knowledge  of  the  amount 
of  traction  being  used." 

AUis  places  his  patients  in  plaster  of  Paris,  after  the  method  of  Lorenz,  for 
a  month  or  six  weeks,  at  the  end  of  which  time  the  child  is  put  in  an  apparatus 
with  adjustable  wings  to  which  the  abducted  thigh  can  be  loosely  bound  and  the 
abduction  gradually  increased  until  an  angle  of  ninety  degrees  is  reached.  His 
apparatus  permits  a  free  motion  save_  in  abduction  and  adduction.  After  ten 
months  this  is  removed  and  the  child  is  allowed  to  have  limited  freedom,  being 
still  in  the  recumbent  posture  for  two  months  more.  It  will  be  seen  from  this 
that  Allis  restrains  his  patients  in  the  recumbent  posture  for  a  year,  while  in  the 
method  of  Lorenz  they  are  in  plaster  of  Paris  for  six,  eight,  or  ten  months,  but 
are  permitted  a  certain  degree  of  locomotion. 

In  ankylosis  at  the  hip  with  malposition,  the  thigh  is  generally  flexed  upon  the 
abdomen  and  adducted  with  outward  rotation.  When  destructive  osteo-arthritis 
has  occurred  the  trochanter  will  be  seen  nearer  to  the  iliac  crest  than  on  the  sound 
side,  a  condition  which  does  not  exist  when  the  ankylosis  has  occurred  from  non- 
destructive arthritis. 

On  account  of  muscular  rigidity  the  exact  condition  of  ankylosis  cannot  usually 
be  determined  without  ether  narcosis.  A  certain  degree  of  mobility  is  present, 
as  a  rule. 

TreatmC7it. — W^hen  the  malposition  is  such  that  usefulness  is  impaired  or  com- 
fort interfered  with,  an  effort  to  relieve  the  deformity  by  operation  is  justifialile, 
provided  that  all  local  inflammatory  symptoms  are  absent  and  that  the  general 
condition  of  the  patient  is  such  that  no  risk  is  incurred  by  the  procedure.  L^'nder 
ordinary  conditions  the  operation  is  not  attended  with  danger. 

In  osteotomy  at  the  hip  for  the  relief  of  deformity  three  procedures  may  be 
entertained :  Section  of  the  neck  of  the  femur,  just  above  the  great  trochanter 
(Adams,  Fig.  668)  ;  the  intertrochanteric  section  of  Sayre  (Fig.  669) ;  or  the 
subtrochanteric  operation  of  Gant  (Fig.  670).  The  objections  to  Adams'  line 
of  section  is  that  often,  on  account  of  disappearance  of  the  head  and  neck  of  the 
bone,  it  is  impossible;  and,  secondly  and  chiefly,  if  disease  has  existed  at  the  joint, 
thi^s  line  of  section  is  so  near  the  old  seat  of  osteo-arthritis  that  the  process  of 
inflammation  may  be  reestablished.  In  ankylosis,  without  osteo-arthritis  at  the 
hip,  it  is  to  be  preferred.  In  the  vast  majority  of  cases.  Gant's  section — just  at 
the  lower  portion  of  the  lesser  trochanter — is  preferable.  The  objects  to  be  accom- 
plished are,  a  section  of  the  bone  at  this  point  at  a  right  angle  to  the  axis  of  the 
shaft,  rotation  of  the  femur  into  its  normal  position,  and  abduction. 

Subtrochanteric  Osteotomy  at  the  Hip. — The  patient  is  placed  on  the  sound 
side,  so  that  the  femur  to  l3e  divided  is  well  exposed.  The  strict  details  of  anti- 
sepsis should  be  carried  out. 

The  upper  surface  of  the  great  trochanter  is  felt,  and  the  femur  grasped  be- 
tween the  thumb  and  finger.  Upon  the  outer  portion  of  the  femur  an  incision  is 
made,   commencing  about  one  inch  below  the  most  superior  surface  of  the  tro- 


DEFORMITIES 


659 


chanter  major,  and  extending  downward  about  one  inch.  When  the  bone  is  ex- 
posed, the  wound  is  held  open  by  retractors,  and  Vance's  narrow  chisel  introduced 
flatwise  with  the  incision  until  the  bone  is  reached,  when  it  is  turned  so  that  the 
cutting  edge  is  across  the  axis  of  the  femur.  In  a  child  twelve  years  old  the  lower 
portion  of  the  lesser  trochanter  (the  line  of  section)  is  about  one  and  a  half  inch 
below  the  tip  of  the  great  trochanter. 

While  the  limb  is  steadied  by  an  assistant,  a  few  blows  with  the  mallet  drives 
the  chisel  into  the  bone,  which  is  cut  from  one  half  to  three  fourths  through. 


Fig.  668. — Adams'  line  of 
section.    (After  Poore.) 


Fig.  669. — Sayre's  intertro- 
chanteric line  of  section. 


Fig.  070. — Gant's  .subtro- 
chanteric line  of  section. 
(After  Poore.) 


Grasping  the  thigh  near  the  knee  with  one  hand,  while  the  other  steadies  the  part 
above  the  section,  the  remaining  portion  is  readily  fractured  by  carrying  the  thigh 
toward  the  median  line.  The  wound  is  now  .thoroughly  dried,  closed  with  catgut 
sutures,  and  sealed  with  collodion.  A  sterile  gauze  dressing  is  applied.  The  thigh 
is  rotated  slightly  inward,  abducted  to  about  five  degrees  from  the  axis  of  the  spine, 
and  flexed  on  the  abdomen  so  that  the  axis  of  the  femur  joins  that  of  the  body  at 
an  angle  of  fifteen  degrees  (Fig.  671).  If  in  the  position  of  deformity  the  thigh 
is  abducted — a  condition  which  rarely  exists — the  corrected  position  should  be  that 
of  adduction  about  five  degrees  beyond  the  normal.  The  after-treatment  is  the 
same  as  for  fracture  at  this  point,  namely.  Buck's  extension  and  Hamilton's  long 
splint,  or  the  plaster-of-Paris  spica  may  be  used. 

In  order  to  secure  the  necessary  five  degrees  of  abduction,  the  padding  to  the 
splint  should  be  made  several  inches  thicker  opposite  the  acetabulum  than  at  the 
knee,  and  the  thigh  and  leg  should  be  elevated  upon  pillows  enough  to  secure  the 
fifteen  degrees  of  flexion  required.  When  consolidation  occurs  with  the  extremity 
in  this  position,  locomotion  is  good  and  more  comfort  experienced  in  the  sitting 
posture  than  when  the  leg  is  perfectly  straight.  At  the  end  of  four  or  five  weeks 
the  patient  may  be  allowed  to  go  about  on  crutches,  and  in  eight  or  ten  weeks  to 
walk  without  them. 

The  result  to  be  achieved  is  osseous  reunion  at  the  point  of  fracture  with  the 
limb  in  the  improved  position.  A  false  or  new  joint  is  not  to  be  attempted.  The 
hsemorrhage  is  usually  slight,  and  a  few  catgut  ligatures  readily  control  all  bleed- 
ing points.  Forcible  breaking  up  of  adhesions  or  fracture  at  the  joint  is  not  per- 
missible. Adams'  section  is  made  through  an  incision  in  the  line  advised  for 
hip-joint  exsection.  Its  center  should  correspond  to  a  point  just  above  the  great 
trochanter.  The  chisel  should  be  preferred  to  the  saw  in  making  the  section,  on 
account  of  the  bone  dust  and  detritus  left  by  this  latter  instrument. 

Sayre's  line  is  half-way  between  Adams'  and  Gant's  lines.  The  bone  should 
be  divided  squarely  across.     The  attempt  to  form  an  artificial  ball-and-socket  joint 


660 


DEFORMITIES 


by  making  a  concavitj^  in  the  upper  fragment,  or  rounding  ofE  the  upper  extremitj' 
of  the  lower  fragment,  is  not  advisable,  because  it  prolongs  the  operation,  and  is 
apt  to  be  followed  by  necrosis,  with  ultimate  anlqdosis.  It  is  better  to  accomplish 
reunion  in  an  improved  position  at  once. 

The  deformities  of  the  shaft  of  the  femur  are  also  congenital  and  acquired. 
An  occasional  congenital  malformation  is  due  to  failure  of  development  of  this 
bone  in  its  long  axis.  The  femur  may  not  be  more  than  six  inches  in  length,  while 
the  tibia  and  fibula  are  normal  in  development.  As  a  consequence  of  rickets,  the 
femur  is  occasionally  curved  outward,  causing  gC7iu  varum,  or  bowlegs,  although, 
as  will  be  seen  later,  the  bones  of  the  leg  are  chiefly  involved  in  this  deformity. 

Shortening,  with  or  without  angular  malposition,  is  sometimes  seen  after  badly 
united  fractures. 

For  the  relief  of  these  deformities  osteotomy  and  osteoclasis  ma}'  be  done  when 
the  deformity  is  suiBcient  to  justify  the  operation.  In  osteotomy  the  incision  should 
•be  along  the  anterior  and  external  aspect  of  the  thigh  farthest  removed  from  the 
vessels.  The  only  artery  of  importance  here  is  the  descending  branch  of  the  external 
cireimiflex.  Osteoclasis  is  not  permissible  unless  the  fracture  can  be  effected  by 
manual  force.  In  recent  and  badly  united  fractures,  and  in  rachitic  subjects  this 
may  be  done.  The  osteotome  is  preferable  to  the  osteoclast.  In  overlapping  frac- 
tures, with  marked  shortening  (two  to  five  inches),  if  the  union  is  not  angular,  the 

deformity  may  be  corrected  and  lateral  spinal 
curvature  obviated  by  a  compensating  high  shoe. 
If  for  assthetic  reasons  the  patient  insists  upon 
it,  a  section  may  be  taken  from  the  sound  femur 
and  the  ends  brought  together,  as  was  done  by 
Weir  in  one  instance.  The  conditions  which  will 
justify  this  j)rocedure  are,  however,  rare. 


Fig.  671. — The  proper  position  of 
the  extremity  after  subtrochan- 
teric osteotomy.     (After  Poore.) 


Fig.  672. — Genu  valgum — Knock-knee  or  in-knee. 
(After  Poore.) 


Occasionally  overlapping  and  badly  united  fractures  of  the  thigh  will  be  met 
with  in  which  the  callus,  which  persists,  is  so  extensive  that  operation  at  the  seat 
of  fracture  is  impossible. 

The  deformities  of  the  lower  extremity  of  the  femur  are  those  of  hypertrophy 
or  elongation  of  one  or  the  other  condyle.  The  oiiter  condyle  is  only  exceptionally 
enlarged.  The  consideration  of  these  pathological  changes  belongs  properly  to 
genu  valgxim  and  varum. 


DEFORMITIES 


661 


Genu  Valgum. — When  a  normal  subject  stands  erect,  the  inclination  of  the 
femur  of  each  side  is  inward  and  toward  its  fellow,  until  the  internal  condyles  are 
abnost  in  contact.  In  other  words,  by  actual  measurement  in  a  descent  of  eighteen 
inches  from  the  head  to  the  condyloid  extremity,  a  separation  of  seven  inches  be- 
tween the  acetaljula  is  reduced  to  three  and  a  half  inches  from  center  to  center  at 


K*^ 


Fig.  6  *  3. — Genu  valgum  and  varum  in  the  same 
patient,  in  Mount  Sinai  Hospital. 


Fig.  674. — The  same,  after  osteotomy-  of  both 
femora,     (The  author's  case.) 


the  knee.  This  obliquity  is  slightly  increased  in  females,  owing  to  the  broader 
development  of  the  peMs. 

If  the  articular  facets  of  both  tibise  are  brought  firmlj''  and  evenly  in  contact 
with  the  condyles  of  the  femur,  it  will  be  seen  that  the  axis  of  the  tibia  is  parallel 
with  that  of  the  spine. 

Any  outward  deviation  of  this  parallelism  of  the  tibia  with  the  axis  of  the 
body  constitutes  the  deformitv  known  as  genu  valgum,  knock-knee,  or  in-knee 
(Fig.  672). 

Knock-knee  may  occur  on  one  or  both  sides,  in  both  sexes  and  at  all  ages.  In 
exceptional  instances  genu  valgtmi  may  exist  on  one  side  and  varum  on  the  other, 
as  shown  in  Figs.  673  and  6T4.  Knoch-hnee  is  usually  acquired;  occasionally 
congenital.  It  is  most  frequently  seen  in  children  and  young  adults  suffering 
from  an  acquired  or  hereditary  dyscrasia.  As  to  the  causes,  we  must  look  chiefly 
to  changes  in  the  bones  at  or  near  the  knee-joint.  Any  interference  with  the 
normal  processes  of  nutrition  and  development  in  the  bones  wiU.  account  for  most 
cases  of  knock-knee,  and  the  chief  pathological  condition  is  either  that  of  rachitis, 
or  one  so  closely  allied  to  it  that  a  distinction  is  difficult. 

The  most  classical  osseous  lesion  in  genu  valgum  is  the  enlargement  of  the 
internal  condyle  as  compared  to  the  external,  and  the  resulting  increase  of  the  nor- 
mal obliquitv-  of  the  tibio-femoral  articulation.  This  increased  obHquitj'  may  be 
due  to  h}-pertrophy  of  the  inner  condyle;  or  to  hypertrophy  of  the  inner  half  of 
the  upper  tibial  epiphysis ;  to  atrophy  of  the  outer  condyle,  or  atrophy  of  the  outer 
half  of  the  upper  tibial  epiphysis;  to  a  combination  of  two  or  more  of  these  con- 
ditions; to  a  curve  of  the  femur  (convexity  inward)  from  rickets,  and  to  a  like 
curve  of  the  tibia  and  fibula. 


662  DEFORMITIES 

There  is  no  anatomical  reason  why  the  internal  condyle  should  enjoy  a  better 
nutrition  and  greater  development  than  the  outer.  There  is,  however,  a  very  good 
mechanical  explanation  in  this,  that  by  reason  of  the  marked  obliquity  of  the 
femoral  axis  and  the  perpendicular  direction  of  the  tibial  shaft  when  the  subject 
is  standing  erect,  the  line  of  gravity  brings  the.  greater  weight  upon  the  outer 
facet  of  the  tibia  and  the  corresponding  condyle  of  the  femur.  The  distribution 
of  this  pressure  equally  over  the  entire  articular  surface  belongs  to  the  muscles 
controlling  this  joint;  but  owing  to  the  excessive  number  "and  greater  power  in 
the  adductor  as  compared  to  the  abductor  group,  the  internal  obliquity  is  main- 
tained and  the  pressure  upon  the  outer  articular  surfaces  increased.  In  the  rachitic 
condition  the  bones  are  softened,  and  become  distorted  under  pressure,  and  as  a 
result  of  muscular  action,  while  such  deformities  are  resisted  by  the  normal  bones. 

Knock-knee  from  incurvation  of  the  shaft  of  the  femur  alone  is  exceedingly 
rare.  When  not  due  to  abnormal  changes  in  the  condyles,  the  cause  of  this  deform- 
ity will  usually  be  found  in  rachitic  disease  of  the  tibia  and  fibula,  in  which  these 
bones  are  bent  inward  at  the  middle  or  lower  third.  The  principal  changes  in 
the  soft  parts  are  elongation  of  the  internal  lateral  ligaments,  and  a  contractured 
condition  of  the  biceps  and  popliteus  muscles. 

Symptoms. — The  symptoms  of  knock-knee  vary  in  different  stages  of  the  de- 
formity. The  approximation  of  the  knees  is  a  feature  less  noticeable  than  the 
divergence  of  the  tibise.  With  the  lower  extremities  fully  extended,  and  the  knees 
in  contact,  it  will  be  noticed  that  the  inner  malleoli  are  separated  from  a  few  inches 
to  a  foot  or  more.  AVhen  the  lesion  is  due  to  changes  in  the  inner  condyle  of  the 
femur,  it  will  be  observed  that,  if  the  leg  is  flexed  upon  the  thigh  at  an  angle  of 
ninetjf  degrees,  the  deformity  is  less  apparent;  and  if  complete  flexion  is  made  in 
mild  cases  of  in-knee,  it  will  disappear  altogether ;  i.  e.,  the  tibia  in  extreme  flexion 
will  be  parallel  with  the  femur.  The  patella  is  displaced  outward,  and  locomotion 
is  more  or  less  impaired.  Pain  is  often  j)resent,  from  the  unnatural  strain  upon 
the  tissues,  and  fatigue  with  the  slightest  exertion  is  often  noticed. 

The  diagnosis  rests  upon  the  recognition  of  the  symptoms  just  detailed,  and 
the  prognosis  is  generally  favorable  when  judicious  and  persistent  treatment  is 
instituted.  Constitutional  remedies  and  mechanical  appliances  are  indicated  early 
in  the  disease,  and  operative  interference  is  justifiable  when  mechanical  treatment 
cannot  effect  a  cure. 

The  first  indication  is  met  in  out-of-door  life,  good  food,  diversion,  tonics,  cod- 
liver  oil,  and  the  hypophosphites  of  lime  and  soda. 

The  mechanical  treatment  should  be  insisted  upon  in  all  cases  of  children  in 
which  the  deformity  is  not  exaggerated,  and  should  be  persisted  in  for  several 
years,  if  necessary.  Any  mechanism  which  is  applicable  in  this  deformity  must 
afford  a  fixed  point,  opposite  to  and  on  the  external  aspect  of  the  region  of  the 
knee-joint,  from  which  constant  traction  may  be  made.  The  apparatus  of  Pro- 
fessor Sayre  (Fig.  675)  will  be  found  of  great  use  in  meeting  the  chief  indications. 
It  consists  of  a  pelvic  belt  of  steel,  padded  so  as  not  to  excoriate,  and  a  bar  of 
steel  hinged  at  the  knee  and  passing  down  from  the  belt  to  the  sole  of  the  shoe, 
where  it  is  fastened,  as  in  the  long  hip  splint  already  described. 

Opposite  each  knee,  and  just  above  and  below  the  joints — in  order  to  distribute 
the  pressure  over  a  wider  area,  and  thus  prevent  chafing  or  excoriations — are  padded 
belts  or  bands  which  siarround  the  limb;  these  are  attached  to  the  side-bars.  and. 
may  be  tightened  at  will  in  exercising  the  required  traction  to  overcome  the 
deformity.  Elastic  tension  by  means  of  rubber  bands  or  webbing  may  also  be  util- 
ized in  this  manner.  The  hinges  at  the  knees  allow  the  patient  to  bend  these 
joints  in  walking,  and  to  assume  the  sitting  posture.  The  instrument  should  be 
worn  during  the  waking  hours,  and  at  night  it  will  be  advisable  to  make  extension 
from  both  legs  by  Buck's  method.  The  cost  of  this  apparatus  places  it  beyond 
the  reach  of  many  patients,  and  in  this  class  of  cases  renders  early  operative  inter- 
ference more  justifiable. 

Osteotomy  of  the  femur  for  the  correction  of  chronic  cases  of  genu  valgum  is 
an  operation  practically  free  from  danger,  and  yields  excellent  results.  The  sec- 
tion should  be  made  above  the  joint,  and  away  from  it  a  sufficient  distance  to  avoid 


DEFORMITIES 


663 


all  danger  of  entering  the  articulation  or  injuring  the  epiphysis.  Linear  section 
should  be  preferred,  since  it  is  simpler  than  cuneiform  osteotomy,  and  is  equal 
to  the  correction  of  all  cases  excepting  those  in  which  there  is  extreme  angularity 
at  the  seat  of  deformity.  Such  conditions  rarely,  if  ever,  occur  in  the  femur. 
The  older  operations  of  Ogston,  Eeeves,  Chiene,  and  Macewen,  which  involved  the 
joint,  are  practically  discarded.  They  are  objectionable  in  this,  that  they  invade 
the  joint  and  endanger  the  functions  of  this  important  articulation.     Transverse 

section  above  the  epiphyseal  line  from  the 
outside  (MacCormac)  or  inner  side  (Mac- 
ewen)  should  be  preferred  (Fig.  676). 


Fig.  675. — Sayre's  apparatus  for  the  correc- 
tion of  knock-knee.      (After  Sa^-re.) 


Fig.  676. — a,  MacCormac's  line,     b,  Macewen's  line. 
(After  Poore.) 


Macewen's  Operation. — In  this  procedure  it  is  intended  to  divide  the  femur  at 
a  right  angle  to  its  axis  through  two  thirds  to  three  fourths  of  its  thickness,  at  a 
point  well  above  the  level  of  the  lower  epiphysis.     In  a  child 
ten  years  old  the  line  of  section  should  be  one  and  three  quar- 


FiG.  677. — Ogston. 


Fig.  678.— Reeves. 


Fig.  679.— Chiene. 


Fig.  680. — Macewen. 


ter  inches  above  the  most  dependent  portion  of  the  articular  surface  of  the  internal 
condyle,  and  in  an  adult  two  and  a  half  inches. 

Strict  aseptic  precautions  should  be  taken.  If  Esmarch's  bandage  is  applied 
as  high  as  the  middle  of  the  thigh,  the  wound  will  be  kept  dry  and  the  operation 
greatly  facilitated.  Flex  the  leg  on  the  thigh  and  rotate  the  thigh  outward  so  as 
to  bring  the  inner  aspect  of  the  joint  upward.  Make  an  incision  one  inch  long, 
following  the  direction  of  the  internal  condyloid  ridge.  The  center  of  this  incision 
should  be  opposite  the  point  of  section  above  given.     The  internal  saphenous  vein 


664  DEFORMITIES 

and  the  anastomotica  magna  artery  should  be  avoided,  and  the  tubercle  for  the 
insertion  of  the  tendon  of  the  abductor  niagnus  felt.  As  soon  as  the  bone  is 
reached  the  chisel  is  carried  down  to  it,  parallel  with  the  incision,  and  immediately 
turned  with  its  cutting  edge  at  a  right  angle  to  the  axis  of  the  femur.  The  inner 
and  anterior  shell  of  compact  tissue  should  be  first  divided,  and  when  the  posterior 
portion  is  cut  through  tlie  osteotome  should  be  directed  to  the  front  so  that  when 
struck  with  the  mallet  it  will  be  carried  away  from  the  vessels.  As  soon  as  the 
bone  is  cut  through  two  thirds  of  its  thickness,  the  remaining  piece  may  be  frac- 
tured by  grasping  the  limb  above  and  below  the  section,  and  using  the  other  hand 
for  a  fulcrum  and  the  leg  as  a  lever,  which  is  carried  outward.  As  soon  as  the 
bone  snaps,  the  leg  is  handed  to  an  assistant,  who  is  directed  to  steady  it  by 
making  strong  extension.  The  wovmd  should  now  be  thoroughly  dried,  a  dress- 
ing of  sterile  gauze  applied,  and  the  tourniquet  removed.  Firm  compression 
with  the  roller  is  essential  to  prevent  bleeding.  The  limb  should  be  brought  into 
the  straight  position  by  extension,  and  steadily  held  until  a  plaster-of-Paris  bandage 
is  put  on  and  hardened.  This  dressing  is  allowed  to  remain  for  four  or  five  weeks, 
as  in  simple  fracture,  when  it  is  removed,  and  passive  motion  made  at  the  joint. 
It  is  reapplied  for  a  week  longer,  and  then,  as  a  rule,  may  be  discontinued.     Mac- 

Cormac's  procedure  is  practically  the  same 
as  the  above,  with  the  exception  that  the  sec- 
tion is  made  from  the  outer  side  of  the  femur. 
Of  these  two  operations  the  incision  from 
the  outer  side  (MacCormac's)  is  preferable, 
for  the  reason  that  there  are  no  vessels  in  the 
way.  On  the  inner  side  the  long  saphenous 
vein  and  the  anastomotica  magna  artery  are 
endangered.  Moreover,  it  does  not  matter 
from  which  side  the  bone  proper  is  divided, 
as  far  as  the  correction  of  the  deformity  is 
concerned.  When  the  tibia  and  fibula  are 
involved  in  the  deformity,  section  of  these 
bones  may  be  required  at  the  same  or  a  sub- 
sequent operation. 

Ge7iu    Varum. — In    bowleg,    or    outward 
curvature  of  the  lower  extremity,  one  or  both 
members  may  be  involved.    The  bones  of  the 
Fig.  68i.-Geim  varum,  or  bowlegs.  l^g  are  Usually  alone  involved,  although  in 

(After  Poore.)  sonie  instances  the  femur  may  take  part  in 

the  deformity  (Fig.  681). 
The  principal  cause  of  bowlegs  is  rickets,  the  softened  bones  yielding  to  the 
weight  of  the  iDody  or  to  muscular  contractions.  Genu  varum  is  usually  met  with 
in  childhood,  but  may  occur  in  adults  who  are  rachitic.  In  treatment,  the  indica- 
tions are  the  same  as  for  knock-knee.  The  adjustment  of  any  mechanical  appa- 
ratus is,  however,  more  difficult.  Splints  shoiTld  be  adjusted  to  prevent  further 
deformity,  or  the  patient  should  be  prevented  fron  bringing  the  weight  of  the 
body  upon  the  diseased  bones.  In  the  meanwhile  every  effort  should  be  made  to 
correct  the  dyscrasia.  A.S  long  as  the  bones  remain  in  the  softened  condition  of 
rickets,  operative  interference  is  not  indicated.  Osteotomy  of  the  tibia  and  filjula 
at  the  point  where  the  outward  curve  is  most  pronounced  will,  in  the  majority  of 
instances,  correct  the  deformity.  In  extreme  cases  it  may  be  necessary  to  malce 
sections  at  two  or  more  points.  If  the  femur  is  involved  it  should  also  be  divided, 
although  this  complication  will  rarely  be  met  with.  The  details  of  the  operation 
and  the  after-treatment  are  practically  the  same  as  for  genu  valgum. 

Osteoclasis  should  be  substituted  for  osteotomy  in  those  cases  in  which  the  frac- 
ture may  be  accomplished  with  little  force  and  with  the  hands  of  the  operator. 
It  is  objectionable  when  performed  with  the  osteoclast,  for  the  reason  that  the 
soft  tissues  are  bruised  to  an  extent  which  does  not  occur  in  osteotomy.  Moreover, 
the  line  of  fracture  cannot  be  directed  with  the  same  accuracy  as  in  cutting  with 
the  chisel. 


DEFORMITIES 


665 


Anl-ylosis  at  the  Knee,  with  Malposition. — For  the  correction  of  this  deformity 
osteotomy  is  at  times  performed.  When  the  degree  of  malposition  is  extreme,  it 
may  become  necessary  to  divide  the  femur  at  a  point  from  three  to  four  inches 
above  tlie  most  dependent  portion  of  the  articular  surface  of  this  bone.  If  after 
this  section  the  limb  cannot  be  brought  out  straight,  division  of  the  tibia  just 
below  the  tuberosity  may  be  done.  Exsection  of  the  knee  is,  however,  a  preferable 
operation;  and,  since  in  modern  practice  the  danger  of  this  procedure  is  so  greatly 
diminished,  it  is  believed  that  the  operation  through  the  articulation  will  super- 
sede section  of  the  bone  in  continuity. 

Talipes. — Clubfoot  is  a  deformity  in  which  there  exists  either  an  abnormal 
relation  between  the  bones  of  the  foot  to  each  other,  or  to  the  tibia  and  fibula. 


Fig.  682. 
Congenital  talipes  equinus. 


Fig.  6S3. 
(.\fter  Churchill.) 


There  are  six  simple  and  several  compoimd  forms  of  talipes.  The  simple  varieties 
are  talipes  equinus,  calcaneus,  varus,  valgus,  cavus,  and  planus.  Among  the  com- 
pound forms  are  those  of  equino-valgus,  equino-varus,  calcaneo-valgus,  calcaneo- 
varus,  etc. 


Fig 
Acquired  talipe=!  equinu^ 


In  Fig 

mu-icleb 


Fig.  685. 
there  has  occurred  complete  paralysis  of  the  extensor 
i.Mter  Churchill.) 


In  talipes  equinus  the  heel  is  drawn  up  and  the  weight  of  the  body  falls  upon 
the  plantar  aspect  of  the  metatarsus,  the  toes  and  phalanges;  the  gastrocnemius 


666 


DEFORMITIES 


and  soleus  are  shortened,  the  tendo  Achillis  tense,  and  in  extreme  cases  the  heel 
cannot  be  brought  down  to  the  ground.  Callosities  are  formed  upon  the  sole  of 
the  foot  along  the  metatarso-phalangeal  line.  When  paralysis  of  the  anterior 
muscles  of  the  leg  has  taken  place,  the  toes  are  turned  under,  as  in  Fig.  685.  In 
this  condition  there  are  atroph}'  and  complete  loss  of  power  in  the  tibialis  anticus, 
peroneus  tertius,  extensor  longus  digitorum,  and  extensor  pollicis  muscles. 

Simple  talipes  equinus  is  not  of  very  frequent  occurrence,  since  it  is  almost 
always  complicated  with  inward  rotation  of  the  tarsus,  or  talipes  equino-varus. 

Treatment.— Vi'lieii  comjjlete  paralysis  has  not  occurred,  and  if  taken  early, 
talipes  equinus,  wdiether  congenital  or  acquired,  may  be  cured,  or  marked  de- 
formity prevented,  by  the  institution  of  proper  treatment.  Section  of  the  tendo 
Achillis  is  rarely  necessary  when  the  case  has  not  been  neglected.  The  propriety 
of  tenotomy  can  be  determined  by  the  degree  of  resistance  met  with  in  the  effort 
to  bring  the  sole  of  the  foot  to  a  right  angle  with  the  axis  of  the  leg.  If  this 
cannot  be  accomplished,  or  if,  when  the  tarsus  is  firmly  flexed  on  the  leg,  pressure 
upon  the  sural  muscles  produces'  a  painful  and  marked  spasm  (Sayre),  tenotomy 
is  indicated,  especially  in  those  patients  who  cannot  afford  tlie  long-continued 
expense  of  mechanical  treatment,  and  who  of  necessity  cannot  remain  long  in  the 
hands  of  an  experienced  surgeon.  In  simple  equinus  the  indications  are  to  over- 
come the  muscular  contraction  by  artificial  appliances,  and  to  restore  the  normal 
tonicity  and  power  to  the  anterior  tibial  group  of  muscles. 

When  a  child  is  born  with  talipes  equinus  (and  all  forms  of  congenital  club- 
foot should  be  treated  from  birth),  deformity  of  the  bones  of  the  foot,  and  the 
too  great  stretching  or  elongation  of  the  anterior  muscles,  may  be  prevented  by 
the  following  simple  means :  Cut  a  piece  of  light  board  as  wide  as  the  sole  and  a 
little  longer  than  the  foot,  and  cover  it  with  adhesive  plaster  in  such  a  way  that 
the  sticking  surface  is  neyt  to  the  skin.  This  is  laid  along  the  sole  of  the  foot, 
to  which  it  is  fastened  by  adhesive  strips,  and  a  light  bandage,  leaving  the  end  of 
the  board  to  project  a  little  beyond  the  toes.  From  the  end  of  the  board  traction 
may  be  made  by  a  strip  of  plaster  carried  upward  and  fastened  along  the  front 
of  the  leg  near  the  knee,  sufficient  tension  being  exercised  to  draw  the  foot  into 
its  natural  position.  Or,  if  deemed  necessary,  artificial  muscles  (rubber  tubing) 
may  be  attached  from  tlie  tip  of  the  board  to  insertions  fastened  near  the  knee 
on  the  antero-lateral  aspects  of  the 
leg.  The  apparatus  must  be  carefully 
readjusted  whenever  it  becomes  loose 
or  causes  pain. 


Fig.  686. — Bones  of  tlir  Icit  o!  an  , adult  with 
talipes  equinub  (After  Chance  and  Noble 
Smith.) 


/■I'/'/Ji/fj- 
FlG    6S7  — .S  n  rr  ■-  i  lublo 
(  Vfter  ba)ic  ) 


When  the  patient  is  able  to  walk,  simple  cases  of  equinus  may  be  corrected  by 
wearing  a  stiff,  solid,  and  well-constructed  laced  shoe,  which  will  hold  the  instep 
well  down  and  keep  the  sole  of  the  foot  in  close  contact  with  the  sole  of  the  shoe. 
The  weight  of  the  body,  falling  upon  the  anterior  portion  of  the  foot,  will  aid 
in  carrying  the  heel  to  the  ground  with  each  step. 

In   more   obstinate  cases   the   Sayre   shoe    (Fig.    687)    more  nearly  meets  the 


DEFORMITIES 


667 


mechanical  indications  tlian  any  other  apparatus.  When  there  is  no  inversion 
of  the  foot  (varus),  the  lateral  rubber  muscle  J  G  is  unnecessary.  In  ordering 
this  shoe  it  is  advisable  to  send  to  the  instrument-maker  the  shoe  at  the  time 
worn  bj'  the  patient,  and  with  this  the  distance  from  the  sole  of  the  heel  to  the 
upper  articular  margin  of  the  tibia,  as  well  as  the  circumference  of  the  leg  at  this 
point.  To  this  may  be  added  the  measurements  around  the  foot,  at  the  bases  of  the 
toes,  and  around  the  malleoli.  In  all  cases  of  talipes  in  walking  children  and  adults 
it  is  important  that  all  excoriations  be  healed  before  an}-  appliance  is  adjusted. 

The  idea  must  not,  however,  be  entertained  that  the  simple  application  of  the 
shoe,  or  any  mechanical  appliance,  will  correct  the  deformity.  The  after-treatment 
is  a  most  important  feature  in  these  cases.  Electricity  and  massage  are  important 
adjuvants.  The  weaker  galvanic  current  should  be  preferred,  the  positive  pole  being 
placed  along  the  track  of  the  nerve  which  supplies  the  afEected  muscles,  while  the 
negative  sponge  is  carried  over  the  bellies  of  these  muscles.  The  application  should 
be  made  about  twice  each  week,  while  massage  should  be  employed  twice  daily. 

In  those  cases  where  tenotomy  is  deemed  advisable,  the  operation  is  performed 
as  follows:  The  patient  being  placed  under  the  influence  of  an  anesthetic,  the 
tarsus  is  flexed  forcibly  upon  the  leg,  in  order  to  place  the  tendo  Achillis  and 
plantar  fascia  upon  the  stretch:  a  slight  puncture  of  the  skin  is  then  made,  a 
little  anterior  to  the  tendon,  and  on  the  inner  side  of  the  leg,  slightly  above  the 
malleolus ;  this  opening  is  now  carried  to  the  edge  of  the  tendon  by  traction  upon 
the  integument,  and  the  tenotome  introduced,  with  its  ilat  surface  toward  the  ' 
tendon.  The  tension  upon  the  tissues  is  now  relaxed,  and  the  edge  of  the  knife 
turned  toward  the  parts  to  be  divided;  the  tarsus  is  flexed  strongly  upon  the  leg, 
and  the  tendon  again  made  tense,  when  the  knife  is  pressed  forward  and  outward 
through  the  tendon,  which  separates  with  a  very  audible  snap.  The  thumb  of 
the  operator  being  placed  over  the  tendon  externality,  acts  as  a  guide  and  support, 
preventing  the  blade  from  passing  through  the  integument  and  causing  an  open 
wound,  an  accident  which  should  be  carefully  avoided.  As  soon  as  the  division 
of  the  tissues  is  effected,  the  blade  of  the  knife  should  be  withdrawn,  flatwise,  and 
the  thumb  of  the  operator  slipped  oxev  the  slight  puncture,  which  is  at  once  cov- 
ered with  one  or  two  strips  of  adhesive  plaster;  the  plantar  fascia  can  be  divided 
in  a  similar  manner,  if  desirable,  the  whole  foot  being  then  enveloped  in  cotton,  and 

a  snug  roller-bandage  applied.  The  foot  is  now 
secured,  by  mechanical  appliances,  at  a  right 
angle  to  the  leg,  as  heretofore  described.  Divi- 
sion of  the  extensor  tendons  of  the  toes  is  not 
often  required.  The  best  point  of  section  is  just 
over  the  metatarso-phalangeal  articulation. 


Fig.  688, 


—Congenital  talipes  calcaneus. 
(Aitei  Churchill.) 


Fig.  689. — Acquired  talipes  calcaneus. 
(After  Churchill.) 


Talipes  Calcaneus. — In  this  rare  form  of  clubfoot  the  toes  are  drawn  upward 
and  the  tarsus  flexed  upon  the  tibia;  impairment  of  function  exists   in  one  or 


668 


DEFORMITIES 


more  of  the  sural  mnseles;  the  tibialis  anticus,  peroneus  tertius,  extensor  longus 
digitoruin.  and  poUieis  are  shortened.  This  deformity  may  be  either  congenital 
or  acquired  (Mgs.  688,  689).  It  is  usually  met  with  in  children,  or  may  occur 
at  any  period  of  life,  from  rupture  of  the  tendo  Achillis,  or  paralysis  of  the  mus- 
cles of  the  calf  of  the  leg,  ununited  fracture  of  the  os  ealcis,  etc.  In  this  condition 
the  mechanical  and  surgical  appliances  and  treatment  are  exactly  opposite  to  those 
of  the  preceding  variety.  An  ununited  section  of  the  tendo  Achillis  should  he 
corrected  by  cutting  down  upon  this  tendon  at  the  seat  of  the  division,  freshening 
the  divided  ends,  and  sewing  them  together  with  silk  sutures.  Mild  cases  of  cal- 
caneus may  be  relieved  by  the  wearing  of  a  well-fitting  laced  shoe,  the  weight  of 
the  body  aiding  in  correcting  the  deformity.  When  the  toes  cannot  be  brought 
down  without  the  aid  of  additional  pressure,  the  apparatus  in  construction  similar 
to  the  one  recommended  for  flat-foot  can  be  applied.  The  object  to  be  obtained 
is  to  elevate  the  heel  and  depress  the  toes  by  mechanical  means.  For  this  purpose, 
the  shoe  as  devised  by  Dr.  Sayre  (Fig.  690)  is  admirably  adapted.  This  is  a 
strong  laced  shoe,  with  steel  rods  running  up  on  either  side  of  the  leg  to  a  collar 
below  the  knee,  tire  rods  being  hinged  at  the  ankle  to  allow  of  free  motion  at  this 
joint;  from  the  'heel  of  the  shoe  a 
small  steel  spur  is  seen,  to  which  is 
secured  a  strong  piece  of  elastic,  pass- 
ing up  to  the  collar  around  the  leg. 
This  rubber  artificial  muscle,  tak- 
ing the  place  of  the  gastrocnemius 
and  soleus  muscles,  if  made  of  suf- 
ficient tension,  will  elevate  the  heel 
and  restore  the  foot  to  its  normal 
position.  There  are,  hovever,  vari- 
ous instruments  for  the  correction  of 
this  deformity,  the  surgeon  modify- 
ing the  shoe  as  may  be  required  to 
suit  each  case.  In  addition  to  the 
mechanical  appliances,  the  after-treat- 
ment, by  electricity,  massage,  etc., 
should  be  carried  out  as  in  other  forms 
of  cluljfoot  where  atrophy  of  the  mus- 
cles and  loss  of  power  exists. 


Fig.  690.  — Su- 


re's  .■<hoe   for  talipes   calcaneus. 
(After  Sayre.) 


Fig.  691. — Talipes  equino-varus  in  an  adult. 
(After  Churchill.) 


Talipes  Varus  and  Equino -Varus. — These  deformities  consist  of  an  inward  rota- 
tion of  the  foot,  and  are  the  most  common  forms  of  talipes  (Figs.  691,  694).  The 
majority  of  cases  are  those  in  which  spastic  contraction  of  the  sural  muscles  also 
occurs  (equino-varus).  Talipes  varus  and  equino-varus  are  more  often  congenital, 
but  are  frequently  acquired,  one  or  both  feet  being  involved.     The  degree  of  de- 


DEFORMITIES 


669 


formit}^  varies  from  slight  inversion  of  the  foot  to  the  most  exaggerated  form  in 
"(vhich  the  sole  looks  upward,  while  in  the  act  of  walking  the  dorsum  rests  upon 
the  ground. 

The  changes  which  the  structures  of  the  foot  undergo  are  shortening  of  the 
plantar  fascia  and  the  internal  lateral  ligaments,  together  with  a  contraetured  con- 
dition of  the  tibialis  anticus  and  posticus  muscles  and  permanent  deformity  of 
the  bones.     The  displacement  of  the  bones  of  the  tarsus  will  correspond  to  the 


Fig.  C93. 
Three  grades  of  talipes  variis.      (.-Uter  Churchill.) 


extent  of  the  deformity;  the  astragalus  being  tilted  downward,  the  scaphoid  is 
displaced  inward  and  downward  by  the  action  of  the  tibialis  posticus,  the  tubercle 
on  this  bone  becoming  very  prominent;  there  is  in  addition  marked  rotation  at 
the  astragalo-scaphoid  and  calcaneo-cuboid  junctions,  the  displacement  being  espe- 
cially marked  in  this  last-named  articulation. 

t\rhen  the  deformity  exists  at  birth,  if  not  corrected  earl}',  the  bones  will  be- 
come misshapen,  and  the  deformity  permanent. 

The  treatment  of  talipes  equino-varus  in  the  infant  consists  in  the  application 
of  small  rubber  bands  or  pieces  of  tubing,  which  will  make  constant  and  gradual 
traction  in  the  line  of  the  weakened  or  paralyzed  muscles.  This  (BarweU's)  method 
is  as  follows: 


[^;__;Mfi|ii   %j 

nil 

^:?*1    SI 

^=- 

|ilK'v/%i 


Fig.  695.— (After  SajTe.) 


Fig.  697.— (Mter  Sayre.) 


Cut  a  piece  of  strong  adhesive  plaster  into  the  shape  of  a  fan,  which  is  split 
into  four  or  five  strips  converging  toward  the  apex  of  the  fan  (Fig.  695).  "The 
apex  of  the  triangle  is  passed  through  a  wire  loop  with  a  ring  in  the  top  (Fig.  696), 
brought  back  upon  itself,  and  secured  by  sewing.  The  plaster  is  firmly  secured 
to  the  foot  in  such  a  manner  that  the  wire  eye  shall  be  at  a  point  where  we  wish  to 


670 


DEFORMITIES 


imitate  the  inseiiion  of  the  muscle,  and  that  it  shall  draw  evenly  on  all  jDarts  of 
the  foot  when  the  traction  is  applied.  Secure  this  by  other  adhesive  straps  and 
a  smoothly  adjusted  roller. 

"  The  artificial  origin  of  the  muscle  is  made  as  follows :  Cut  a  strip  of  tin  or 
zinc  plate,  in  length  about  two  thirds  that  of  the  tibia,  and  in  width  one  quarter 
the  circumference  of  the  limb  (Fig.  697).  This  is  shaped  to  fit  the  limb  as  well 
as  can  be  done  conveniently.  About  an  inch  from  the  upper  end  fasten  an  eye 
of  wire.  Care  should  be  taken  not  to  have  this  too  large,  as  it  would  not  confine 
the  rubber  to  a  fixed  point.  The  tin  is  secured  upon  the  limb  in  the  following 
manner:  From  stout  (moleskin)  plaster  cut  two  strips  long  enough  to  encircle 
the  limb^  and  in  the  middle  of  each  make  two  slits  just  large  enough  to  admit  the 
tin,  which  will  prevent  any  lateral  motion;  then  cut  a  strip  of  plaster,  rather  more 
than  twice  as  long  as  the  tin,  and  a  little  wider;  apply  this  smoothly  to  the  side 
of  the  leg  on  which  the  traction  is  to  be  made,  beginning  as  high  up  as  the  tuber- 
osity of  the  tibia.  Lay  upon  it  the  tin,  placing  the  upper  end  level  with  that 
of  the  plaster  (Fig.  698).  Secure  this  by  passing  the  two  strips  above  mentioned 
around  the  limb   (Fig.  699),  then  turn  the  vertical  strip  of  plaster  upward  upon 


Fig.  69S.— (From  Barwell.) 


Fig.  699.— (From  Barwell.) 


the  tin.  A  slit  should  be  made  in  the  plaster  where  it  passes  over  the  eye,  in  order 
that  the  latter  may  protrude.  The  roller  should  then  be  continued  smoothly  up 
the  limb  to  the  top  of  the  tin.  The  plaster  is  again  reversed  and  brought  down 
over  the  bandage,  another  slit  being  made  for  the  eye,  and  the  whole  secured  by 
a  few  turns  of  the  roller.  A  small  chain,  a  few  inches  in  length,  containing  a 
dozen  or  twenty  links  for  graduating  the  adjustment,  is  then  secured  to  the  eye 
in  the  tin. 

"  Into  either  end  of  a  piece  of  ordinary  rubber  tubing,  about  one  quarter  of  an 
inch  in  diameter  and  two  to  six  inches  in  length,  hooks  of  the  pattern  shown  in 
Fig.  700  are  fastened  by  a  wire  or  othe'r  strong  ligature  (Fig.  701).  One  hook 
is  fastened  to  the  wire  loop  on  the  plaster  on  the  foot,  and  the  other  to  the 
chain  above  mentioned,  the  various  links  making  the  necessary  changes  in  the 
adjustment. 

"The  dressing,  when  corSplete,  is  shown  in  Fig.  699."     (Sayre.) 

A  roller  should  now  be  carefully  and  smoothly  applied  over  the  plaster  and 
between  the  leg  and  the  artificial  muscles. 

When  the  muscles  cannot  be  obtained,  and  in  mild  cases  in  which  the  foot  may 


DEFORMITIES  671 

be  brought  readily  into  position,  a  correction  maj'  be  effected  by  means  of  one 
or  more  strips  of  adhesive  plaster  as  follows :  One  end  of  the  strip  is  laid  upon 
the  dorsum  of  the  foot,  near  the  bases  of  the  third  and  fourth  toes,  whence  it 
is  carried  in  a  slightly  spiral  direction  to  the  inner  border  of  the  sole,  and 
across  the  sole  to  the  outer  margin  of  the  foot.  As  the  foot  is  now  brought 
into  a  normal  position  b}-  the  hand  of  the  operator,  the  strip  of  plaster  is  laid 
along  the  outer  and  anterior  aspect  of  the  leg  and  thigh,  and  firml}^  secured  by 
encircling  strips  of  the  same  material.  A  bandage  over  all  will  hold  the  dressing 
in  position. 

When  the  patient  is  able  to  walk,  the  clubfoot  shoe   (Fig.  C8T)   will  give  the 
greatest  satisfaction.     The  rubber  muscles  should  be  applied  and  regulated  in  such 


Fig.  702. — Iron  shoe  for  talipes  varus  and  cquino-  Fig.  703. — Iron  shoe  for  talipes  varus  and  equino- 

varus.  varus  in  position.      The  adhesive  strips  and 

bandage  have  been  omitted  in  the  cut. 

a  way  that  the}'  will  imitate  as  nearly  as  possible  the  normal  action  of  the  muscles 
they  are  intended  to  assist.  A  less  expensive  instrument,  one  which  yields  good 
results  in  the  milder  forms  of  talipes  equino-varus,  and  which  may  be  readily 
made  by  any  ordinary  worker  in  iron,  is  sho\ni  in  Fig.  T02.  It  consists  of  a  sole- 
piece  of  sheet  iron,  which  is  riveted  to  a  heel-piece  of  the  same  material,  and  is 
roomy  enough  to  hold  the  heel  of  the  patient  without  chafing.  It  should  be  nicely 
padded  to  prevent  the  danger  of  excoriations.  To  this  heel-piece  is  attached,  by 
a  hinge  joint  with  limited  forward  and  backward  motion,  an  iron  bar  which 
extends  to.  the  padded  iron  collar  around  the  leg,  near  the  knee.  The  foot  of  the 
patient  is  secured  to  the  sole-piece  by  adhesive  plaster,  with  the  aid  of  the  instep 
strap  shown  in  Fig.  703.  and  a  flannel  roller  carried  over  all.  As  the  perpendicular 
bar  is  now  carried  parallel  with  the  leg,  and  held  in  this  position  by  buckling  the 
collar  around  the  leg  at  the  laiee,  the  foot  is  turned  outward  and  held  in  its  normal 
position.     An  ordinary  lacing  shoe  should  be  worn  over  the  brace. 

An  apparatus,  the  mechanism  of  which  is  somewhat  similar  to  this,  is  highly 
recommended  by  ^ilr.  Beeves,  and  is  shown  in  Fig.  704. 

The  modification  of  Scarpa's  shoe  (Fig.  705)  possesses  some  advantages  over 
the  iron  shoe  above  described,  and  should  be  preferred  to  it  when  it  can  be 
obtained. 

Tenotomy  and  fascioiomy  will  be  found  necessary  in  a  large  proportion  of 
cases  of  talipes  equino-varus,  and,  when  not  essential  to  ultimate  success,  it  will 
greatly  expedite  the  permanent  restoration  of  the  member  to  its  normal  position. 
The  application  of  Esmarch's  bandage  from  the  toes  to  above  the  knee,  though 
not  essential,  renders  the  operative  procedure  more  rapid  and  easy  of  execution. 
The  tendo  Achillis  is  divided  as  heretofore  directed.  In  addition,  the  tibialis 
anticus  and  the  tibialis  posticus  will,  as  a  rule,  require  to  be  divided.  The  tendon 
of  the  tibialis  anticus  should  be  cut  subcutaneously  about  one  inch  above  its 
insertion  into  the  internal  cuneiform  bone  by  introducing  the  tenotome  beneath 
it  from  the  middle  line  of  the  foot.  It  can  be  made  prominent  by  forcible  eversion 
of  the  foot.     Division  of  the  tendon  of  the  tibialis  posticus  is  best  effected  by  an 


g72  DEFORMITIES 

incision  parallel  with  the  inner  border  of  the  tibia  just  above  the  internal  malleo- 
lus, where  it  lies  in  close  relation  to  this  surface  of  the  bone.  As  soon  as  it  is 
exposed,  an  aneurism  needle  should  be  passed  beneath  it,  when  it  can  be  drawn 
out  throuo'h  the  wound  and  divided  with  the  scissors.    Subcutaneous  section  of  this 


Outer  view.  Inner  ^  lew 

Fig.  704. — Reeves'  universal  shoe,  as  it  is  being  applied  in  the  treatment  of  talipes  equino-varus. 

(After  Reeves.) 

tendon  is  a  very  difficult  and  uncertain  procedure,  while  no  mistake  is  possible 
through  an  open  wound.  If  careful  antisepsis  is  practiced,  and  if  the  wound  is  at 
once  closed  with  catgut  sutures,  no  suppuration  can  occur.  The  plantar  fascia 
should  be  divided  bj'  introducing  the  tenotome  flatwi.se  under  the  fascia  from  the 
inner  border  of  the  foot,  turninj>;  the  edge  outward,  and  cutting  the  fascia  as  it 
is  made  tense.  Several  lines  of  section  through  this  fascia  may  be  made  when 
necessary.     Each  puncture  should  be  closed  with  aseptic  collodion. 

Tarsotomy. — In   exaggerated   and   chronic   cases   of  congenital   talipes   equino- 
varus  a  wedge-shaped  exsection  of  a  portion  of  the  tarsus  will  at  times  permit  a 


Fig.  705. — Modified  Scarpa's  shoe  for  talipes  varus  and  equino--varus.      (After  Reeves.) 

restoration  of  the  foot  to  its  normal  position,  and  serve  to  restore  in  great  part  the 
usefulness  of  the  member.  In  two  recent  cases  in  which  I  performed  this  operation 
the  most  gratifying  results  were  obtained.  In  each  case  before  operation  the 
patient  walked  with  the  dorsum  of  the  foot  on  the  floor,  and,  in  one  instance, 
the  toes  pointed  directly  backward. 

After  Esmarclr's  bandage  has  been  applied,  a  free  incision  is  made  along  the 
fibular  side  of  the  foot,  extending  from  below  the  external  malleolus  to  the  tarso- 
metatarsal junction.     All  the  tissues  should  be  lifted  from  the  bones  by  the  peri- 


DEFORMITIES 


673 


osteal  elevator,  and  the  wedge-shaped  section  of  the  tarsus  removed  by  the  gouge 
or  chisel.  The  anterior  j^ortion  of  the  astragalus  will  require  to  be  removed,  and 
as  much  of  the  tarsus  should  be  exsected  as  is  needed  to  permit  the  restoration  of 
the  foot  to  the  natural  position;  for  it  is  not  only  necessary  to  evert  the  foot,  but 
to  make  at  the  same  time  a  marked  rotation  of  that  part  of  the  member  anterior  to 
the  line  of  section.  The  tendo  Achillis  should  now  he  divided,  and,  as  soon  as  the 
proper  position  is  obtained,  the  incision  closed  and  covered  with  iodoformized 
gauze,  and  a  light  dressing  and  compression  bandage  applied  tight  enough  to  arrest 
all  oozing.  A  plaster-of-Paris  dressing  is  now  put  on,  and  the  foot  held  in  position 
until  this  hardens.  This  last  procedure  can  be  facilitated  by  adjusting  two  strips 
of  adhesive  plaster,  one  of  which  will  serve  to  hold  the  foot  at  a  right  angle  to 
the  axis  of  the  leg,  and  the  other  to  keep  it  rotated  outward  while  the  plaster  is 
being  applied  and  is  hardening.  The  dressing  may  be  removed  not  earlier  than 
the  fifteenth  day,  and  should  not  be  disturbed  for  a  month  unless  it  is  necessitated 
from  soiling. 

In  a  certain  proportion  of  cases  which,  from  neglect  to  institute  treatment 
immediately  after  birth,  will  not  yield  to  the  measures  heretofore  advised,  great 
benefit  may  be  derived  from  forcible  manual  twisting  of  the  foot  into  a  proper 
position.  The  patient  is  usually  anesthetized  and  the  foot  is  so  held  that  no 
strain  will  be  brought  upon  the  ankle-joint  while  the  process  of  twisting  the  bones 
of  the  tarsus  is  being  carried  out.  While  the  patient  is  still  under  the  anaesthetic 
a  plaster-of-Paris  dressing  should  be  applied  and  the  foot  held  in  the  improved 
position  until  the  plaster  is  firmly  set.  This  may  be  repeated  from  time  to  time, 
and  should  be  considered  one  of  the  best  methods  in  the  treatment  of  all  forms 
of  talipes  in  which  there  is  marked  distortion  of  the  foot  and  tarsus.  If  these 
means  were  carried  out  in  all  cases,  the  need  for  tarsotomy  would  be  exceptional. 


)  — Congenital  talipes  valgus, 
( \fter  Churchill  ) 


Fig.  707. — AcquiieJ  talipes  -valgus. 
(Aftei  Churchill  ) 


Talipes  Valgus. — In  this  deformity  the  normal  arch  of  the  foot  is  lost,  and  the 
foot  is  everted  (Figs.  706,  707).  The  contracted  muscles  are  the  peroneus  longus 
and  brevis,  while  the  paralysis,  as  a  rule,  affects  the  tibialis  posticus,  anticus,  and 
flexor  muscles.  When  the  tarsal  arch  gives  way,  the  plantar  fascia,  calcaneo-cuboid 
ligaments,  and  short  flexors  become  stretched,  and  the  tibialis  anticus  is  elongated. 
The  yielding  of  these  muscles  may  be  due  to  paralysis,  or  to  strain  from  the  habit 
of  carrying  heavy  weights. 

Treatment. — In  talipes  valgus  in  an  infant  the  eversion  may  be  corrected  by 
means  of  the  adhesive  strips  applied  as  in  the  treatment  of  varus.  The  direction 
of  traction  is  of  course  opposite.  The  artificial  muscles,  after  the  method  of 
Barwell,  are  also  as  applicable  here  as  in  varus.     The  iron  shoe,  made  with  the 


674 


DEFORMITIES 


bar  to  come  upon  the  inner  side  of  the  leg,  is  as  serviceable  in  mild  cases  of  valgus 
as  in  varus  or  equino-varus.  This  apparatus  is  always  worn  inside  of  an  ordinary 
shoe.  N'yrop's  boot  (Fig.  710)  is  highly  recommended  by  Mr.  Eeeves.  It  con- 
sists of  a  stiff-soled  lacing  shoe,  with  a  leg  collar  and  iron  or  steel  bar  attached 
to  the  outer  side  of  the  shoe,  with  a  lateral  hinge  opposite  the  outer  malleolus.  To- 
the  inner  side  of  the  sole,  near  the  heel,  is  attached  a  strong  piece  of  elastic  web- 


FiG.  708. — Inner  view  of  a  severe  valgus  of  the  right  foot.     (After  Reeves.)       1,  Inner  malleolus.. 
2,  Inner  surface  of  head  of  astragalus.     3,  Tubercle  of  scaphoid. 

bing,  by  which  inversion  of  the  foot  is  effected  by  buckling  the  strap  to  the  collar 
near  the  knee. 

When  tenotomy  of  the  peronei  muscles  is  indicated,  they  should  be  divided 
subcutaneously  from  three  quarters  to  one  and  a  half  inch  (owing  to  the  age  of 
the  patient)  above  the  external  malleolus.  Cuneiform  tarsotomy  may  be  applied 
to  the  correction  of  this  deformity  in  exaggerated  cases  in  adults.  When  the  bones 
are  thoroughly  ossified  it  will  be  impossible  to  change  the  shape  of  these  organs 
and  restore  the  normal  shape  of  the  part  by  an}^  mechanical  apparatus,  no  matter 
how  persistent  in  its  use.  The  incision  is  made  along  the  inner  side  of  the  foot, 
and  the  apex  of  the  conical  section  must  be  at  the  outer  border  of  the  tarsus. 


-Inner  view  of  the  bones  of  a  severe  valgus.      (After  Reeves.)      1,  Tubercle   of  scaphoid. 
2,  Astragalus.     3,  Os  ealcis.     4,  Internal  cuneiform  bone.     5,  First  metatarsal. 


The  details  of  the  operation  and  the  after-treatment  are  practically  the  same  as 
given  for  equino-varus. 

A  very  satisfactory  and  successful  method  of  treating  flat-foot  is  that  of  Dr. 
Eoyal  Whitman,  and  is  as  follows :  ^ 

"  The  foot  is  first  immersed  in  hot  water,  afterward  vigorously  massaged,  espe- 
cially about  the  dorsum,  and  is  then  slowly  forced  into  a  position  of  adduction.  .  .  . 
This  inward  twisting  is  at  first  resisted  by  a  mixed  voluntary  and  involuntary 
muscular  spasm,  which  gradually  gives  way  under  steady  pressure.  When  the 
limit  of  adduction  has  been  reached  the  foot  is  firmly  held  until  all  pain  has 
subsided,  when  the  patient  is  instructed  to  make  voluntary  movements  of 
flexion  and  extension.  The  foot  is  then  released  and  twenty  minutes  of  volun- 
tary exercises  follow,  and  at  intervals  during  the  day  the  patient,  by  active  mus- 

'  Dr.  Walter  C.  Wood,  "Annals  of  Surgery,"  vol.  xvi,  p.  407. 


DEFORillTIES 


675 


cular  efforts  and  passive  motion,  eonstantlr  works  to  one  end — namely,  to  xegaia 
the  lost  power  of  adduction — while  once  dailj-  the  twisting  is  performed  by  the 
surgeon. 

■■  During  the  ten  days,  more  or  less,  while  this  active  massage  is  being  per- 
formed, the  patient  is  allowed  to  walk  a  little,  wearing  whatever  support  has  been 
selected.  The  most  satisfactory  in  practice  and  the  most  scientiiic  in  theory  of 
any  support  with  which  I  am  acquainted  is  the  brace  advocated  by  Dr.  Whitman. 
In  each  case  it  is  made  on  an  iron  mold,  with  the  cast  of  the  foot  in  the  corrected 
position  as  a  model.  The  cast  is  taken  a  few  days  after  the  twisting  by  removing 
the  plaster  splint  for  the  purpose.  Another  plaster  splint  is  usually  applied  until 
the  brace  is  ready.  This  steel  brace  extends  from  just  behind  the  ball  of  the  great 
toe  to  a  point  in  front  of  the  inner  tuberositT,"  of  the  os  calcis ;  thus  the  foot  rests 
on  its  normal  supports,  the  inner  flange  reaches  to  a  point  in  front  of  and  a  little 
below  the  internal  malleolus,  while  the  small  outer  one  fits  in  behind  the  base  of 
the  fifth  metatarsal.  The  weight  on  the  outer  border  forces  the  inner  part  of  the 
brace  snugly  up  against  the  weak  arch.  The  time  required  from  the  date  of 
the  anajsthesia  until  a  patient  can  walk  about  with  some  comfort  on  these  well- 
fitting  supports  is  about  three  weeks.  In  a  foot  without  stiffness,  of  course,  they 
can  be  applied  without  the  preliminary  twisting  and  massage. 

"  These  braces  should  be  worn  some  six  or  more  months,  depending  upon  the 
severitjr  of  the  case,  during  which  time  the  patient  should  himself  continue  the 
twisting  and  massage.    They  can  then  graduallv  be  laid  aside.    The  ultimate  result 


Fig.  711. — Showing  the  surface  of  the  sole  which 
rests  upon  the  floor  in  a  normal  foot.  (After 
Sayre.) 


no. — Xj-rop's  shoe  for  tahpes 
(.Aiter  Reeves.) 


■algus. 


Fig.  712. — Cast  of  the  right  foot  in  a  case  of 
talipes  planus,  at  the  Polyclinic. 


is  a  flexible  foot  in  a  correct  position  without  pain,  and  can  justly  be  considered 
a  radical  cure.  Although  the  proper  application  of  this  brace  requires  some  skill 
in  the  use  of  plaster  of  Paris  and  a  wise  attention  to  the  details  of  massage,  the 
results  warrant  its  use  ia  an  important  case." 

Talipes  Cavus. — Hollow-foot  is  almost  alwavs  an  acquired  deformity,  although 
it  may  be  congenital.  It  occurs  with  talipes  calcaneus,  equinus,  and,  in  a  mild 
degree,  may  complicate  varus  and  equino-varus.  In  this  deformity  the  antero- 
fiosterior  arch  of  the  foot  is  exaggerated,  the  plantar  fascia  and  the  muscles  of  the 
plantar  region  which  have  their  origin  behind  the  medio-tarsal  joint,  and  are  in- 
serted anterior  to  this  articulation,  are  shortened.  The  plantar  fascia  and  the 
ealcaneo-cuboid  ligaments  are  also  shortened.  The  sole  of  the  foot  no  longer  rests 
upon  the  floor,  as  in  the  normal  condition  (Fig.  Til),  but  touches  only  at  the  heel 
and  along  the  metatarso-phalangeal  line. 

Any  inflammatory  process  of  the  plantar  region  may  induce  contraction  of  the 
fascia  or  ligaments;  or  spastic  contraction  of  the  muscles  of  this  region  from  local 
or  remote  causes  may  produce  this  deformity.  Commencing  before  the  bones  are 
softened,  the  distortion  of  the  foot  is  apt  to  become  permanent  tmless  essection 
or  crushing  is  performed.  Of  these  two  procedures,  tarsoclasis  is  the  most  readily 
accomplished;  but,  when  the  tarsoclast  cannot  be  had,  section  through  the  tarsus. 


676 


DEFORMITIES 


with  a  thorough  division  of  the  plantar  fascia,  will  be  justifiable.     Fortunately, 
few  instances  will  occur  where  such  harsh  procedures  will  be  called  for. 

In  recent  cases  the  deformity  may  be  relieved  by  wearing  a  plain  shoe  with  a 
low,  broad  heel  and  straight,  thick  sole.  The  plantar  fascia  should  be  divided  in 
all  cases  which  do  not  readily  yield  to  mechanical  treatment. 

Talipes  Planus. — Flat-foot  has  been  partially  considered  with  talipes  valgus, 
with  which  condition  it  is  almost  always  associated.  The  antero-posterior  arch 
of  the  foot  is  more  or  less  obliterated,  and  in  severe  cases  the  anterior  portion  of 
the  sole  spreads  out  or  widens  in  its  transverse  diameter   (Fig.  712). 

The  plantar  fascia  and  calcaneo-cuboid  ligaments  are  stretched,  the  internal 
lateral  ligaments  of  the  ankle-joint  are  generally  involved,  while  the  tibialis  anticus 
and  the  muscles  of  the  plantar  aspect  of  the  foot  are  elongated.  The  principal 
cause  of  this  deformity  is  the  habitual  carrying  of  heavy  burdens,  or  pressure  of 
the  superincumbent  weight  of  the  body  upon  the  arch  of  the  foot,  together  with 
lack  of  tonicity  in  the  muscles,  and  of  strength  in  the  ligaments  and  fascia. 

Treatment. — It  is  exceedingly  difficult  and  in  the  majority  of  cases  impossible 
to  correct  this  deformity.  The  best  method  is  to  support  the  arch  of  the  foot  by  a 
comfortable  adjustment  of  pressure  by  inserting  a  piece  of  felt  in  the  sole  of  the 
shoe,  just  beneath  the  arch. 

The  deformities  of  the  toes  are  congenital  and  acquired.    The  congenital  devia- 
tions from  the  normal  are  the  presence  of  one  or  more  supernumerary  toes  {poly- 
dactylus),  or  the  absence  of  one  or  more  of 
these  members  {syndactylns) . 

In  polydactylus  the  most  frequent  super- 
numerary toe  is  one  connected  with  the  great 
toe,  attached  usually  on  its  inner  or  tibial 
aspect,  near  the  junction  of  the  metatar- 
sal bone  and  phalanx.     In  k  rare  case  of  this 


Fig.  713. 


-Syndactylus  in  the  right  foot  of  a  boy. 
(After  Reeves.) 


Fig.  714. — Sayre's  method  of  treating  hal- 
lux valgus.     (After  Say  re.) 


deformity,  reported  by  Professor  Sayre,  there  were  eight  toes  on  the  right  and 
ten  on  the  left  foot. 

Treatment. — All  minor  deformities  the  removal  of  which  does  not  endanger 
the  life  of  the  individual,  or  diminish  the  usefulness  of  the  member  afl'ected, 
demand  amputation  within  the  first  year  or  two  of  life,  before  the  patient  is  old 
enough  to  become  conscious  of  possessing  a  deformity. 

Syndactylus  is  a  term  applied  not  only  to  the  partial  or  entire  absence  of  one 
or  more  fingers,  but  also  to  the  condition  known  as  congenital  lueb-toe. 

Web-toes  may  be  treated  in  the  same  way  as  web-fingers.  If  neglected  until 
the  child  is  old  enough  to  become  accustomed  to  the  deformity,  operation  is  of 
doubtful  propriety. 

When  one  or  more  toes  are  missing,  even  when  the  deformity  is  offensive  to 
the  sight,  the  question  of  operative  interference  (except  for  relief  from  pain) 
should  depend  upon  the  degree  of  usefulness  enjoyed  by  the  deformed  member. 
An  important  principle  in  the  surgery  of  the  foot  is  to  save  every  particle  of 
surface  for  the  support  of  the  body.  This  conclusion  gains  additional  force  in 
the  ability  to  conceal  the  deformity  by  a  properly  constructed  shoe. 


DEFORMITIES  677 

The  acquired  deformities  of  the  toes  result  in  almost  all  cases  from  improperly 
adjusted  shoes.  The  displacement  may  be  in  all  directions,  although  those  of  the 
great  and  little  toes  are  usually  toward  the  median  line  of  the  foot.  The  middle 
toes  may  be  flexed  in  one  joint,  extended  in  another,  or  crossed  over  each  other. 

Hallux  valgus,  or  displacement  of  the  great  toe  toward  the  fibular  or  outer  side 
of  the  foot,  is  a  common  deformity  (Fig.  715).  In  exaggerated  instances  mechan- 
ical or  surgical  interference  is  demanded.  Hallux  valgus  is  caused  chiefly  by  shoes 
which  are  pointed  at  the  tip  and  are  too  short  for  the  foot.  It  may  also  occur 
with  clubfoot,  and  generally  with  talipes  varus  and  planus.  The  action  of  the 
muscles  inserted  into  the  base  of  the  great  toe  must  not  be  altogether  overlooked 
in  the  jetiology  of  this  deformity.  Of  the  five  muscles  which  arise  from  the  tarsus 
and  metatarsus  and  are  inserted  into  this  toe^  all  but  one  tend  to  carry  it  toward 
the  fibular  side  of  the  foot. 

In  being  displaced,  the  great  toe  is  usually  carried  above  the  second  or  third 
toe,  occasionally  beneath  it.  The  phalanx  is  more  or  less  completely  dislocated 
from  the  original  articular  surface  of  the  metatarsal  bone,  being  twisted  around  to 
its  outer  lateral  aspect.  The  cartilage  of  the  old  portion  disappears,  and  a  new 
joint  surface  is  developed  on  the  external  aspect  of  the  metatarsal  bone.  From 
pressure,  a  callosity  of  varying  thickness  develops  over  the  tip  of  the  metacarpus, 
adding  greatly  to  the  appearance  of  deformity. 

Treatment. — Mild  cases  of  hallux  valgus  may  be  cured  by  elastic  tension  stead- 
ily applied,  as  follows :  A  soft  kid  or  chamois-skin  cover  is  made  for  the  affected 
toe,  and  to  the  end  of  this  a  piece  of  thin  elastic  webbing  is  attached.  To  the 
webbing  a  strip  of  adhesive  plaster  is  stitched,  and  this  is  carried  around  the  heel 
and  is  made  to  adhere  along  the  outer  side  of  the  foot  in  such  a  way  that  the 
webbing  is  made  to  draw  the  toe  outward  (Fig.  714). 

In  severe  cases,  operative  interference  can  alone  restore  the  toe  to  its  normal 
position.  The  operation  consists  in  an  incision  made  along  the  inner  side  of  the 
foot,  the  center  of  which  is  over  the  angular  projection  at  the  end  of  the  metatarsal 
bone.  The  callosity  should  be  removed,  the  joint  opened,  a  wedge-shaped  segment 
removed  from  the  end  of  the  metatarsal  bone  and  the  phalanx.  Enough  should 
be  removed  with  the  exsector  or  metacarpal  saw  to  permit  the  bones  to  be  brought 
into  piroper  jjosition,  where  they  should  be  held  by  a  plaster-of-Paris  dressing 
applied  over  light  sterile  gauze.  The  toe  should  be  held  well  abducted  until  the 
gypsum  is  hard.  It  is  removed  at  the  expiration  of  three  weeks.  Fig.  715  is  from 
a  cast  taken  from  a  patient  at  Mount  Sinai  Hospital  upon  whom  I  did  this  operation 
in  both  feet.     The  degree  of  correction  is  shown  in  Fig.  716. 

This  operation  is  preferable  to  that  of  osteotomy  of  the  first  metatarsal  bone 
just  behind  the  articulation,  for  the  reason  that  the  callosity  and  projection  oppo- 
site the  joint  can  only  be  removed  by  excision. 


Fig.  715. — Hallux  valgus.     (From  a  patient  at  Fig.  716. — The  same,  after  operation. 

Mount  Sinai  Hospital.) 

Hallux  varus,  or  pigeon-toe,  is  a  much  rarer  deformity,  and  occurs  usually  as 
a  result  of  cicatricial  contractions  or  from  spastic  action  of  the  abductor-pollicis 
muscle.  The  treatment  consists  in  adjusting  a  well-made  shoe  that  will  push  the 
toe  into  its  proper  position.  Division  of  any  cicatricial  tissue  or  the  tendon  of 
the  abductor  muscle  may  be  necessary. 


678 


DEFORMITIES 


Displacement  of  the  little  toe  is  usually  inward  an'd  beneath  the  fourth.     The 
same  treatment  maj^  be  applied  in  this  deformity  as  given  for  hallux  valgus. 

Flexion  of  the  toes  may  be  complete  when  there  is  paralysis  of  the  extensor 
muscles.  The  most  usual  form  is  that  in  which  the  first  phalanx  is  tilted  upward, 
that  is,  seemingly  extended,  while  the  distal  phalanx 
is  drawn  downward,  so  that  the  nail  is  to  the  front, 
and  the  tip  of  the  toes  rests  upon  the  ground.  This 
condition  is  also  known  as  liammer-toes. 

The  cause  is  chiefly  one  of  improper  shoeing,  by 
which  the  toes  are  not  allowed  to  be  fully  extended, 
and,  being  held  in  this  cramped  position  by  the  shoe, 
the  muscles  and  fascise  become  permanently  short- 
ened. The  plantar  fascia  is  usually  involved  in 
chronic  cases.  The  extensor  muscles  become  shortened 
as  well  as  the  flexors,  which  are,  however,  the  jDrincipal  agents  in  jDroducing  the 
deformity. 

Extension  of  tlie  toes  beyond  the  normal  line  is  a  rare  condition.    It  could  only 
be  caused  by  paralysis  of  the  flexors. 


Fig.  717. — Apparatus  for  ham- 
mer-toes.     (After  Reeves.) 


Fig.  717a. — Injection  of  cocaine  for  local  antesthesia  in  removing  ingrowing  toe-nail  and  other  minor 
procedures.  1,  The  wheal  caused  by  the  first  injection  into  (not  under)  the  skin;  2,  the  wheal  due 
to  the  second  injection  into  the  skin.  The  needle  for  this  injection  is  inserted  in  tlie  edge  of  the 
area  already  anEesthetized.  It  is  shown  in  the  correct  position  for  the  second  injection.  (Foote's 
"Minor  Surgery.") 

Treatment. — In  mild  cases  of  incipient  hammer-toes  a  cure  may  be  effected 
by  wearing  a  shoe  long  enough  to  allow  these  members  to  be  extended.     In  more 


DEFORMITIES 


679 


chronic  and  obstinate  eases  a  metal  sole  should  be  adjusted  so  that  an  ordinary 
shoe  can  be  worn  over  it.  Just  beneath  the  middle  of  the  toes  is  a  series  of  per- 
iorations  in  the  sole,  through  which  loops  are  passed.  The  toes  are  straightened 
by  traction  on  the  loops,  which  are  tied  below  (Fig.  717).  In  some  instances 
tenotomy  of  the  long  flexor  and  extensor  muscles  and  of  the  plantar  fascia  is 
«ssential.  The  tendons  of  the  extensor  digitorum  should  be  subcutaneously  divided 
just  over  the'  bases  of  the  toes ;  the  flexor  tendons  near  the  middle  of  the  plantar 
surface  of  these  members. 

Bunions  are  callosities  resulting  from  intermittent  jDressure  upon  certain  por- 
tions of  the  foot. 

Corns  are  both  hard  and  soft.  A  hard  corn  differs  from  a  bimion  only  in  size. 
Soft  corns  are  small  ulcers  situated  between  the  toes  or  in  the  fissures  on  the 
under  surface.     They  are  caused  by  friction  of  opposing  surfaces  and  moisture. 

Bunions  and  hard  corns  are  to  be  treated  by  relieving  the  xmnatural  pressure 
■which  caused  them.  Comfortably  fitting,  yet  not  necessarily  loose  shoes,  of  soft 
leather,  should  be  worn.  Pieces  of  Canton  flannel,  cut  into  rings  and  laid  upon 
■each  other  so  that  the  pressure  will  be  distributed  to  the  surfaces  near  the  corn, 
will  be  advisable,  in  simple  cases,  even  when  loose  shoes  are  adopted.  A  small  tuft 
of  cotton  dipped  in  vaseline  will  aid  in  softening  the  hard  covering.  Soft  corns 
may  be  readily  cured  by  inserting  pellets  of  absorbent  cotton  moistened  with  borax 
■dissolved  in  glycerin,  and  applied  so  as  to  protect  the  raw  surfaces  and  prevent 
friction. 

Ingrowing  nail,  caused  by  tight  shoeing  and  uncleanliness,  usually  occurs  on 
the  great  toe. 


Tig.  7176. — Operation  for  ingrown  nail.     A,  the  skin  flaps  reflected;  B,  tlie  section  of  nail 
corresponding  matrix  removed.     (Foote's  "Minor  Surgery.") 


The  palliative  treatment  is  to  cut  away  portions  of  the  nail  near  the  inflamed 
surface,  and  to  protect  this  by  a  pellet  of  lint  moistened  in  Van  Arsdale's  mix- 
ture. The  radical  treatment  requires  the  removal  of  a  portion,  and,  in  very  rare 
instances,  of  the  entire  nail,  with  the  matrix. 

The  following  operation  will  usually  suffice:  The  toes  and  foot  should  be  thor- 
oughly cleansed.  Local  anaesthesia  is  effected  by  introducing  between  the  layers 
■of  the  skin  the  hypodermic  needle  of  the  cocaine  syringe  (one-per-cent  solution) 
on  the  dorsum  of  the  toe,  half  an  inch  behind  the  nearest  surface  of  the  inner 
.aspect  of  the  nail.  Three  or  four  drops  are  forced  out  and  the  needle  is  pushed 
through  and  beneath  the  skin  half  an  inch  farther,  injecting  the  same  quantity 
and  continuing  this  process  along  the  inner  side  of  the  toe  near  the  nail,  waiting 
a  moment  for  the  anaesthesia  to  declare  itself  before  withdrawing  the  needle,  to 
reenter  it  through  the  anterior  margin  of  the  freshly  ansesthetized  zone  (Fig.  717a). 

The  pain  is  insignificant,  the  discomfort  experienced  being  due  to  the  mo- 
mentary distention  of  the  tissites  with  the  injected  liquid.  It  is  also  necessary  to 
inject  about  half  of  the  matrix  and  to  throw  .the  cocaine  between  the  nail  and 


680 


DEFORMITIES 


the  phalanx  in  order  to  get  a  perfect  anesthesia.  In  from  three  to  five  minutes 
insensibility  is  complete.  The  nail  should  now  be  split  from  before  directly  back- 
ward, usually  removing  the  inner  fourth,  together  with  as  much  of  the  matrix 
as  belongs  to  the  strip  removed.  The  operator  should  be  careful  to  remove  the 
matrix  well  down  to  the  bone  (Fig.  717b). 

If  there  is  any  granulation  tissue  present,  it  should  be  scraped  away  with  a 
curette,  and  the  entire  raw  surface  touched  with  a  pellet  of  absorbent 'cotton  dipped 


Fig.  717c. — Sections  of  the  great  toe  to  illustrate  the  pathology  of  ingrown  nail  on  which  successful 
operation  is  based.  The  nail  is  shown  dark,  the  matrix  light.  Note  that  the  matrix  extends  almost 
to  the  joint.  A,  longitudinal  section;  B,  transverse  section  at  point  in  A  marked  by  the  arrow.  The 
dotted  lines  mark  out  the  portion  of  the  nail  and  matrix  which  sliould  be  removed.  (Foote's 
"Minor  Surgery.") 

in  pure  carbolic  acid.  The  acid  is  not  only  antiseptic,  but  analgesic.  A  little 
alcohol  should  be  applied  to  neutralize  the  excess  of  carbolic  acid.  A  pad  of  sterile 
gauze  is  laid  on  and  held  in  place  with  a  bandage.  Fig.  717c  shows  the  anatomy 
of  the  structures  involved  in  this  operation.  ' 

When  a  more  extensive  operation  is  required — that  is,  removal  of  the  entire 
nail- — the  method  just  described  may  be  modified  to  include  the  entire  end  of  the 
toe,  or  the  cocaine  may  be  injected  well  back  near  the  metatarso-phalangeal  articu- 
lation. "  Einging "  a  digit  with  cocaine  ansesthesia  may  be  successfully  accom- 
plished by  injecting  here  first  into  the  skin  for  one  half  of  the  circumference  and 
then  the  other  a  sufficient  quantity  of  the  one-per-cent  solution,  waiting  for  a 
minute,  then  applying  a  small  piece  of  ritbljer  tuljing  as  a  tourniquet  behind  the 
ring  of  cocaine.  After  this  is  temporarily  applied,  the  syringe  should  be  plunged 
more  deeply,  gradually  infiltrating  the  toe  on  either  side  until  all  of  the  tissues 
have  been  subjected  to  the  presence  of  cocaine.  The  tourniquet  should  now  be  loos- 
ened for  thirty  seconds,  allowing  the  circulation  to  sweep  the  cocaine  forward.  It 
should  then  be  tightened  and  the  cocaine  forced  forward  by  pressure  with  the  thumb 
and  finger. 

The  employment  of  this  method  with  the  one-per-cent  solution  of  cocaine  will 
thoroughly  anesthetize  all  the  tissues  beyond  the  tourniquet,  and  by  holding  this 
in  place  bleeding  is  entirely  prevented,  while  the  tissues  in  line  of  incision  are  not 
distended  by  the  injection. 

Should  there  be  any  anxiety  in  regard  to  the  quantity  used  of  even  so  weak  a 
solution  of  cocaine,  constitutional  symptoms  may  be  avoided  by  loosening  the 
tourniquet  for  ten  or  fifteen  seconds,  reapplying  it  for  a  minute,  then  loosening 
it  again  for  fifteen  or  twenty  seconds,  and  repeating  this  for  four  or  five  minutes. 
In  this  way  the  cocaine  is  gradually  let  into  the  circulation  and  creates  no  dis- 
turbance. 

In  removing  the  entire  nail  an  incision  is  first  made  from  the  middle  of  the 
posterior  margin  of  the  nail  directly  backward  for  half  an  inch.  A  second  incision 
across  the  top  of  the  toe,  extending  as  low  down  as  the  most  inferior  portion  of 
the  nail,  on  either  side,  uniting  with  the  central  end  of  the  perpendicular  cut. 


DEFORMITIES  681 

gives  the  entire  wound  a  T-shape.  Tlie  two  quadrilateral  flaps  of  skin  are  now 
dissected  np,  turned  one  to  tlie  right  and  one  to  the  left  side,  and  held  away  by 
the  weight  of  an  artery  forceps  or  by  retractors.  The  nail  should  next  be  split 
from  before  backward  in  the  middle  line,  the  incision  extending  through  the  matrix 
as  far  back  as  the  transverse  incision  through  the  skin.  Both  halves  and  the 
matrix  should  be  thoroughly  extirpated,  all  granulation  tissue  scraped  out,  and  . 
the  foot  dipped  into  a  basin  of  warm  sublimate  solution,  1-2000.  The  flaps  are 
now  brought  into  position,  the  space  formerly  occupied  by  the  horny  part  of  the 
nail  packed  with  sterile  gauze,  and  the  entire  toe  enveloped  in  the  same  material. 
A  narrow  bandage  should  be  applied  firmly  enough  to  hold  the  gauze  in  place, 
and  to  exercise  sufficient  compression  to  prevent  bleeding.  Over  this  a  generous 
piece  of  protective  should  be  thrown  and  a  second  bandage  applied.  When,  in 
applying  this  bandage,  the  elastic  ligature  is  reached,  it  should  be  taken  ofl:  and 
the  roller  carried  on  to  the  foot.  A  single  dressing  usually  suffices,  and  it  need 
not  be  removed  for  ten  days  or  two  weeks. 

The  same  general  technic  will  apply  to  the  treatment  of  twisted  or  deformed 
nails. 

Deformities  of  the  Upper  Extremity — Clavicle. — Congenital  absence  of  por- 
tions of  one  or  both  of  these  bones  may  exist.  No  case  of  complete  absence  of  the 
collar  bone  is  as  yet  on  record.  The  partial  deficiency  may  occur  on  one  or  both 
sides,  and  is  usually  at  the  inner  extremity.  The  indications  in  treatment  are  to 
use  a  figure-of-8  brace  around  the  shoulders  to  prevent  them  from  being  approx- 
imated in  part  by  the  actions  of  the  pectoral  muscles. 

Paralysis  of  the  deltoid  and  serratus  mag7ius  muscles  imparts  to  the  shoulder 
a  deformed  appearance.  In  deltoid  paresis  the  shoulder  is  flattened,  and  the  acro- 
mion process  more  prominent  and  easily  recognized.  The  arm  is  incapable  of 
being  lifted  to  a  right  angle  with  the  spine.  It  may  be  due  to  injury  of  the  cir- 
cumflex nerve,  or  to  a  central  nervous  lesion.  When  the  serratus  magnus  is  para- 
lyzed, the  vertebral  border  of  the  scapula  is  tilted  outward  in  a  position  of  unusual 
prominence.     Neither  of  these  injuries  is  amenable  to  surgical  treatment. 

Ankylosis  of  the  .shoulder  is  more  amenable  to  the  operation  of  exsection  than 
to  forcible  breaking  up  of  the  adhesions.  This  last  procedure  may  be  employed 
in  cases  of  partial  ankylosis  in  which  no  inflammatory  process  is  going  on.  In 
ankylosis  of  the  elboiu-joint  the  same  treatment  is  advisable. 

Congenital  dislocation  at  the  shoulder  is  extremely  rare,  as  is  the  displacement 
due  to  violence  at  birth.  The  diagnosis  between  either  of  these  lesions  and  epi- 
physeal separation  or  fracture  can  with  difficulty  be  made  positive  without  the 
X-ray. 

A  more  common  deformity  is  that  due  to  partial  paralysis  from  injury  to  the 
fibers  of  the  cervico-brachial  nerves.  According  to  Whitman,  the  fifth  and  sixth 
roots  are  more  frequently  compressed.  The  characteristic  paralysis  affects  the 
deltoid,  biceps,  and  supinators  of  the  forearm,  the  arm  as  a  result  hanging  by 
the  side  in  an  attitude  of  in^vard  rotation  and  pronation.  If  seen  soon  after  birth, 
there  is  tenderness  over  the  injured  nerves.  Later  these  symptoms  disappear.  The 
extremity  is  smaller  and  shorter  than  its  fellow,  the  deltoid  more  or  less  atrophied, 
and  frequently  the  shoulder  is  ankylosed. 

The  indication  is  to  overcome  the  inward  rotation  so  that  the  power  of  supina- 
tion of  the  forearm  may  be  utilized.     The  technic  is  as  follows :  ^ 

"  The  child,  having  been  anaesthetized,  is  brought  to  the  edge  of  the  table. 
The  shoulder  is  grasped  firmly  with  one  hand  in  order  to  restrain  the  movements 
of  the  scapula,  and  with  the  other  the  arm  is  drawn  upward  and  backward  over 
the  fulcrum  of  the  thumb,  which  lies  behind  the  joint.  This,  the  so-called  pump- 
handle  movement,  alternately  relaxing  and  stretching  the  contracted  parts,  is 
carried  out  over  and  over  again  with  slowly  increasing  force,  the  aim  being  to 
force  the  head  of  the  bone  forward,  and  thus  to  overcome  the  resistance  of  the 
anterior  part  of  the  capsule.  When  this  has  been  accomplished,  there  is  a  distinct 
depression  behind,  and  the  head  of  the  humerus  projects  in  front,  at  a  point  below 
its  pro2Der  position. 

1  Royal  Whitman,  "Annals  of  Surgery,"  July,  1905. 


682 


DEFORMITIES 


"  One  then  attempts  to  overcome  the  abduction  and  to  force  the  head  upward 
by  changing  the  grasp  on  tire  scapula  and  using  the  thumb  in  the  axilla  as  a  ful- 
crum. When  the  arm  can  be  carried  across  the  chest  to  the  normal  degree  of 
adduction^  the  final,  and  often  most  diiKcult^  part  of  the  process — namely,  to  stretch 
the  tissues  suiSeiently  to  permit  the  proper  degree  of  outward  rotation — is  under- 
taken. This  is  best  accomplished  by  flexing  the  forearm  and  using  this  to  exert 
leverage  on  the  humerus,  care  being  taken,  of  course,  to  avoid  the  danger  of  frac- 
ture. When  the  head  of  the  bone  has  been  replaced,  it  will  often  be  noted  that  the 
tension  on  the  anterior  tissues  causes  flexion  of  the  forearm ;  this  must  be  overcome 
in  the  same  manner,  and,  finally,  the  limitation  to  complete  supination.  The 
extremity  is  then  fixed  in  the  overcorreeted  attitude  by  means  of  a  plaster  bandage 
which  includes  the  thorax.  That  is,  the  arm  is  drawn  backward  so  that  the  head 
of  the  humerus  is  made  prominent  anteriorly,  the  forearm  is  flexed  and  turned 
outward  to  the  frontal  jslane,  while  the  hand  is  placed  in  extreme  supination,  the 
arm  lying  against  the  thoracic  wall. 

''  In  the  more  extreme  cases  it  is  impracticable  to  complete  the  operation  at 
one  sitting.  When,  therefore,  as  much  force  has  been  exercised  as  seems  wise,  a 
plaster  bandage  is  ajDplied,  and  after  an  interval  of  two  weeks  the  fiirther  correc- 
tion is  undertaken. 

"  As  has  been  stated,  when  the  head  of  the  bone  is  forced  forward,  a  distinct 
depression  and  evident  relaxation  of  the  tissues  is  noted  on  the  jiosterior  aspect 
of  the  joint.  The  object  of  the  fixation  is  to  allow  the  contraction  of  the  posterior 
wall  of  the  capsule  and  the  obliteration  of  the  old  articulation,  consequenth^,  the 
part  must  be  fixed  for  a  period  of  at  least  three  months.  When  the  plaster  band- 
age is  removed,  the  after-treatme'nt  is  of  great  importance.  This  consists  of  daily 
passive  forcible  movements  to  the  extreme  limits  in  the  directions  formerly  re- 
stricted ;  namely,  outward-  rotation,  backward  extension,  and  eventually  abduction 
of  the  humerus  and  supination  and  extension  of  the  forearm.  For  in  all  these 
cases  there  is  a  strong  tendency  to  a  return  in  some  degree  to  the  original  posture. 


Fig.  718. — Congenital  lu  an  ol  the  radius  and  vilnar       (From  a  case  at  the  Polyclinic.) 


When  motion  has  become  fairly  free,  the  disabled  member  must  be  regularly  exer- 
cised and  reeducated  in  functional  use.  Under  this  treatment  the  w'eakened  and 
almost  completely  atrophied  muscles  usuallv  gain  surprisingly  in  power  and  ability, 
and  the_  longer  it  is  continued  the  better  will  be  the  final  result.  If  the  deltoid 
muscle  is  completely  paralvzed,  one  cannot  expect  independent  movement  at  the 


DEFORMITIES 


683 


shoulder,  and  the  aim  should  be  to  gain  filjroiis  ankylosis  in  the  attitude  of  out- 
ward rotation  in  order  to  permit  supination  of  the  forearm." 

Deformities  of  the  forearm  are  comparatively  rare.  Of  the  congenital  variety, 
occasionally  there  exists  a  fusion  of  the  two  bones.  The  length  of  the  forearm  is 
normal,  as'  is  the  motion  at  the  elbow-joint,  but  supination  and  pronation  are 
impossible.     In  the  only  case  I  have  ever  seen,  from  which  Fig.  718  is  taken,  the 


Fig.  719. 


-Deformity  resulting  from  subperios      il  i  ^ 
(From  a  cas^  operated  uii    if  tl 


e  radius  for  ostitis. 


hands  were  in  the  prone  position.  Operative  interference  was  not  indicated  in 
this  instance. 

Distortions  due  to  rickets  are  at  times  met  with,  and  may  result  from  the 
action  of  the  muscles  upon  the  softened  bones,  or  to  pressure  from  the  habitual 
carrying  of  burdens  in  the  hands.  In  destruction  of  one  of  the  bones  of  the  fore- 
arm by  ostitis,  or  after  its  removal,  deformity  usually  results,  the  deviation  of 
the  hand  being  toward  the  side  of  the  missing  bone  (Fig.  719). 

Treatment. — In  deformity  after  rickets,  correction  by  osteotomy  is  justitiable 
after  the  disease  is  arrested."^  In  the  distortions  due  to  loss  of  substance  there  is 
little  hope  of  relief.  If  the  loss  on  one  side  is  limited,  exsection  of  a  portion  of 
the  sound  bone  and  reunion  of  the  divided  surfaces  by  wire  sutures  might  be 
entertained. 

ChiMand. — Distortions  of  the  hand,  not  unlike  those  already  detailed  as  oc- 
curring in  the  foot,  yet  far  less  common,  may  be  met  with.  The  deformity  may 
be  at  the  wrist-Joint, "in  the  intercarpal  or  earpo-metacarpal  articulations,  and  may 


DEFORMITIES 


be  due  to  failure  of  development  in  the  bones  of  the  forearm  or  hand,  to  muscular 
paralysis,  to  fracture,  dislocations,  or  cicatricial  contractions. 

In  the  congenital  deficiencies,  the  radius  is  more  often  wanting,  or  only  par- 
tially developed,  allowing  the  hand  to  be  carried  toward  the  radial  side.  The 
carpus  is  occasionally  deficient.  Not  infrequently  the  congenital  cases  are  sym- 
metrical, and  the  lower  extremities  are  also  involved. 

The  muscles  are  deficient  in  some  of  these  cases  of  osseous  malformation.  The 
usual  condition  in  paralysis  is  that  of  flexion  of  the  carpus  and  metacarpus  upon 
the  forearm. 

This  variety  is  termed  palmar;  the  opposite,  dorsal  clubhand.  When  the  dis- 
placement is  lateral  it  is  called  radial  or  ulnar,  as  the  hand  is  carried  outward  or 
inward.     As  in  clubfoot,  there  are  compound  forms  of  clubhand. 

As  to  frequency  in  the  congenital  types,  the  radius  being  chiefly  at  fault,  the 
radial  distortion  is  most  frequent.  When  from  any  cause  the  equilibrium  between 
the  muscles  is  impaired,  the  hand  is  usually  flexed  upoii  the  forearm,  and  the 
condition  is  known  as  palmar  clubhand.  AVith  this  there  may  be  radio-palmar 
or  ulno-palmar  deformity. 

Fracture  of  the  radius  (Colles"),  or  epiphyseal  separation,  may  induce  a  mild 
form  of  radial  clubhand.  ITn^^educed  dislocations  will,  of  course,  cause  deformity. 
Deformities  due  to  cicatricial  contraction,  as  after  burns,  extensive  phlegmons,  etc., 
are  occasionally  met  with. 

The  treatment  of  all  these  different  varieties  of  clubhand  will  depend  upon 
the  particular  cause.  In  the  worst  form  of  congenital  deformity,  amputation  at 
or  shortly  after  birth  should  be  performed.  Other  and  milder  cases  may  be  im- 
proved by  mechanical  appa- 
ratus constructed  to  meet  the  /^  /g 
indications.                                                   (TA  P\ 


Fig.  720. — Supernumerary  digits. 
(After  Reeves.) 


Fig.  721.— Double  hand. 
(After  Reeves.) 


Fig.  722.— Stunted  and 
webbed  hand.  (Af- 
ter Reeves.) 


In  muscular  paralysis  the  same  general  rules  of  practice  as  laid  down  in  club- 
foot due  to  this  cause  should  be  followed.  Tenotomy  may  be  necessary.  The 
extensors  may  be  subcutaneously  divided  about  the  middle  of  the  metacarpal  bones. 
The  flexors  slightly  above  the  wrist-joint.  The  lateral  deformities  also  will  justify 
in  some  cases  division  of  the  contracting  muscles.  The  rule  to  be  followed  is 
to  do  subcutaneous  tenotomy  when  the  tendon  to  be  divided  is  far  enough  away 
from  any  important  nerve  or  vessel  to  allow  a  perfectly  safe  and  sure  division 
of  the  tendon;  if  not,  the  tendons  should  be  exposed  by  incision  under  strict 
antisepsis,  and  each  one  picked  up  on  an  aneurism-needle  and  divided  in  plain 
view. 

The  propriety  of  breaking  up  adhesion  in  ankylosis  with  malposition,  or  of 
resection,  should  be  determined  by  the  condition  of  the  parts  and  of  the  patient, 
and  the  necessities  of  the  case. 

The  Fingers  and  Hand.- — Among  the  congenital  deformities  of  the  fingers  are 
polydactylus,  syndactylus,  and  web-finger,  or  fusion  of  two  or  more  digits.  The 
acquired  deformities  are  due  to  contraction  of  the  palmar  fascia,  of  the  muscles 
and  tendons,  to  paralysis  of  certain  muscles,  and  to  osseous  and  articular  lesions, 
both  traumatic  and  idiopathic. 


DEFORMITIES 


685 


Supernumerary  Finger  (Polydacti/Jus). — The  usual  location  of  one  extra  finger 
is  on  the  radial  side  of  the  tliumb  or  iilnar  aspect  of  the  little  finger,  near  the 
metacarpo-phalangeal  Junction  (Fig.  720).  It  may  or  may  not  possess  phalanges 
or  cartilages.  If  the  phalanges  exist,  a  sj'novial  cavity  will  be  found  at  the  junc- 
tion with  the  metacarpal  bone,  or  with  the  phalanx  of  the  normal  member. 

A  rare  form  of  supernumerary  iingers  is  shown,  in  Fig.  721,  in  which  there  is 
practically  a  double  hand.  Amputation  of  the  supernumerary  members  should 
be  made  soon  after  Ijirth. 

In  S3'ndactylus,  all  or  a  portion  of 
one  or  more  fingers  may  be  wanting 
(Fig.  722).  Amputation  of  the  de- 
formed portion  is  usually  advisable. 


Fig.   723. — Elastic  ligature  passed  tlirough  the 
web.      (After  Fort  and  Noble  Smith.) 


Fig.  724  — Didot's  method  of  operatmg  for  -n-eb- 
fingers.      (.-if ter  Fort  and  >.oble  Smith.) 


CO 


Web-finger  is  most  frequently  congenital,  although  it  may  l^e  acquired.  In  mild 
cases,  where  the  union  between  the  contiguous  surfaces  is  sliglit  and  the  web  is  thin, 
the  following  method  will  succeed:  A  round  elastic  ligature  or  cord  is  carried 
through  the  web  just  in  front  of  the  metacarpo- 
phalangeal articulation,  and  the  ends  are  turned 
back  and  attached  by  a  band  around  the  wrist 
(Fig.  723).  This  is  allowed  to  remain  for  three 
or  four  weeks,  until  the  hole  made  by  the  liga- 
ture is  lined  with  epidermis.  A  second  punc- 
ture should  now  be  made  about  one  inch  in 
front  of  the  first,  the  ligature  passed  through 
this,  and  the  ends  tied.  The  constant  trac- 
tion of  the  elastic  gradually  cuts  through  the 
web,  yet  so  slowl}-  that  the  track  of  the  wound 
becomes  covered  with  epidermis.  This  pro- 
cedure should  be  repeated  until  all  the  web  is 
divided. 

When  the  fingers  are  solidh'  united,  the 
method  of  Didot  should  be  preferred.  An  inci- 
sion is  made  down  the  palmar  surface  of  one 
finger  (the  index,  Fig.  724)  and  along  the  dor- 
sal surface  of  the  adjoining  member  (the  middle 
finger).  The  flaps  are  dissected  up  so  that  the 
one  removed  from  the  palmar  surface  of  the 
index-finger  remains  attached  to  the  middle 
finger,  while  the  posterior  flap  is  attached  along 
the  dorsum  of  the  index-finger.  They  are  then 
sutured  in  position  (Fig.  725). 

In  those  cases  in  which  the  bones  are  only  slightly  united,  the  line  of  union 
may  be  sawed  through.  When  the  bones  are  fused  into  one  solid  mass  an  opera- 
tion is  not  indicated. 


f.  725.  —  Trans"\'erse  sections  of  the 
webbed  fingers,  showing  in  the  upper 
figure  the  line  of  separation  between 
the  two  flaps ;  in  the  middle,  the  out- 
line of  the  separated  flaps :  below,  the 
sutures  are  applied.  (After  Fort  and 
Noble  Smith.) 


686 


DEFORillTIES 


Clironic  flexion  of  one  or  more  fingers  may  result  from  paralysis  of  the  ex- 
tensor muscles,  spastic  contraction  of  the  flexors,  or  from  contractions  of  the 
palmar  and  digital  fascia.  Paralysis  of  the  extensors  may  be  temporary  or  per- 
manent. Lead-poisoning  not  infrequently  leads  to  temporary  impairment  of  the 
function  of  this  group  of  muscles. 

In  neglected  cases  of  chronic  extensor  paralysis,  pennanent  shortening  of  the 
opposing  muscles,  with  contraction  of  the  palmar  fascia,  occurs. 

The  indications  in  treatment  are  to  restore,  if  possible,  the  functions  of  the 
paralyzed  muscles,  and  to  prevent  deformity  by  the  adjustment  of  an  apparatus 
which  will  keep  the  fingers  extended. 

Contraction  of  the  palmar  fascia,  as  a  result  of  any  inflammatory  process,  gives 
rise  to  the  most  common  deformity  of  the  fingers.     Penetrating  wounds  of  the 
|)alm,  or  idiopathic  jjhlegmon,   are   exceedingly   apt 
to  result  in  fascial  contraction  and  chronic  malposi- 
tion of  the  fingers. 

This  process  takes  place  at  times  in  persons  of 
the  gouty  or  rheumatic  diathesis  Avithout  any  marked 
symptom  of  local  inflammation.  The  tendons  are 
not  affected,  as  a  rule,  in  the  earlier  stages  of  Du- 


FlG.  726. — Dupuytren's  contrac- 
tion in  tlie  fascia  of  tiie  palm, 
and  of  the  little  finger.  (After 
Noble  Smith.) 


Fig.  727. — The  same,  m  the  middle  and  rmg  fingers  a,  Con- 
tracted band  of  palmar  fascia  h,  Flexor  tendons  (not  m- 
volved).  c.  Sheath  of  tendons,  d,  Digital  prolongations  of 
palmar  fascia.     (Af ter  W.  Adams  and  Noble  Smith.) 


'puytren's  contraction.     In  old  cases  the  muscles  are  shortened.     The  fascial  con- 
tractions are  well  shown  in  Figs.  726  and  727. 

Treatment. — In  mild  cases,  taken  early  in  the  commencement  of  the  affection, 
a  cure  may  be  effected  by  repeated  stretching  of  the  fascia  by  fully  extending  the 
fingers  involved.     The  instrument  shown  in  Fig.  728,  devised  by  Dr:  Battey,  of 


New  York,  will  be  found  very  useful  in  such  eases.  In  obstinate  cases  fasciotoniy 
is  demanded.  Division  of  the  palmar  fascia  should  be  done  as  follows :  The  hand 
should  be  rendered  thoroughly  aseptic  by  washing  in  sublimate  solution,  and  made 
bloodless  by  Esmarch's  bandage.     The  hypodermic  injection  of  four-per-cent  co- 


DEFORMITIES 


687 


caine  solution  renders  the  operation  painless.  The  delicate  fascia  knife  should  be 
introduced  beneath  the  bands  of  fascia;,  -nhich  can  be  made  prominent  by  extreme 
extension  of  the  lingers,  the  edge  turned  upward,  and  a  thorough  division  effected, 
taking  care  not  to  allow  the  knife  to  cut  through  the  skin.  Every  resisting  band 
should  be  divided  until  the  fingers  can  he  readily  brought  iato  a  position  of  over- 
correction. Two  or  three  lines  of  section  may  be  made  in  the  palm  and  one  or 
two  through  the  digital  prolongations  of  the  fLugers  involved.  By  carefulh^  insert- 
ing the  loiife  closely  beneath  the  fascia,  the  vessels  of  the  palm  and  fingers  may 
be  avoided.  The  palm  should  be  covered  with  a  thick  layer  of  sublimate  gauze, 
and  a  splint  applied  in  order  to  keep  the  fijigers  perfectly  straight.  This  should 
be  worn  for  two  or  three  weeks,  at  which  time  passive  motion  should  be  made  and 
the  splint  reapplied  for  another  week.  After  it  is  removed,  thorough  extension 
should  be  j)racticed  at  least  once  a  day  for  several  months. 

Snap-  or  Jerk-finger. — This  name  has  been  used  to  designate  a  condition  in 
which  free  extension  and  flexion  of  one  or  more  fingers  is  more  or  less  interruf)ted. 
As  the  affected  digit  is  being  flexed  or  extended,  motion  is  arrested  in  a  certain 

position,  and  if  a  violent  effort  is  made,  or 
if  flexion  is  continued  by  aid  from  the  other 
hand,  a  perceptible  jerk  occurs  as  the  ob- 
struction is  overcome.  A  nodtilar  swelling, 
to  the  touch  resembling  the  ganglia  often 
met  with  on  the  back  of  the  wrist,  may  be  felt 
along  the  line  of  the  tendon  at  or  near  the 
metacarpo-phalangeal  joint.  Snap-finger  may 
be  due  to  a  circumscribed  thickenino;  of  the 


1 

Fig.  728a. — Tendon  suture.  A  long  loop 
stitch  left  in  place  to  act  as  a  tendon. 
It  becomes  covered  with  fibrous  tissue 
growing  out  from  the  cut  ends  of  the 
tendon,     (Foote's  "Minor  Surgerj'.") 


Fig.  729. — Showing  the  converging  arrangement  of  the 
dense  connective-tissue  bundles  in  the  finger  around 
the  last  phalanx.     (After  Vogt.) 


tendon,   or   a   disproportion  between  the   size 

of  the  tendon  and  sheath  for  a  limited  area. 

This  condition  is  believed  to  exist,  especially 

in    the    thumb,    where    the    jerk    occurs    in 

one  third   of   all   cases.      Mr.   Eeeves   thinks 

that   in  the  fingers  it  is   chiefly   due  to   the 

synovial  fringes  catching  upon  the  transverse  process  of  the  palmar  fascia.     This 

may  occur  not  only  "  from  thickening  of  this  process  of  fascia,  but  also  from  rolling 

up  or  displacement  of  the  SATiovial  sheaths." 

Snap-finger  ma}'  be  traimiatic  or  idiopathic  in  origin.  Strains  on  the  tendons 
and  fascia  in  the  act  of  lifting,  direct  violence,  as  well  as  the  gotit\-  and  rheumatic 
inflammations,  are  noted  in  the  setiolog}'.  The  treatment  consists  in  passive 
motion,  and  internal  medication  to  correct  anv  dvscrasia.     If  relief  does  not  fol- 


688 


DEFORMITIES 


low   ordinary   measures,   an  incision   should   be   made   and   the   enlargement   dis- 
sected out. 

In  certain  cases  in  which  adhesion  of  the  tendons  to  their  sheaths  and  to  the 
palmar  and  digital  fascia  occur  chiefly  as  a  result  of  penetrating  wounds,  it  will 
— in  order  to  relieve  the  deformity — he  required  to  make  an  open  dissection  and 
divide  the  adhesions  in  plain  view.  Such  operations  can  be  done  with  impunity, 
and  with  an  extraordinary  degree  of  success,  if  the  strict  antiseptic  precautions 


Fig.  729a. — Section  of  terminal  segment  of  finger.  An  abscess  may  form  between  the  dorsal  skin  and 
the  matrix  of  the  nail  at  A ;  or  between  the  matrix  and  the  formed  nail  at  -B;  or  between  the  nail  and 
the  underlying  skin  at  C;  or  betw^een  the  skin  and  the  front  of  the  phalanx^  as  shown  in  D.  (Foot3's 
"Minor  Surgery.") 

are  observed.  Esmarch's  bandage  is  essential  to  the  operation,  and  cocaine  anaes- 
thesia I  have  frequently  demonstrated  to  be  iDcrfectly  satisfactory  in  these  proce- 
dures. The  wound  should  be  closed  at  once  with  fine  silk  sutures.  Catgut  is  not 
sufficiently  reliable  in  this  region.  The  danger  of  inflammation  and  contractions 
of  the  fascia  from  opening  into  the  hand  under  sublimate  irrigation  and  careful 


Fig.  729i. — Acute  paronychia  of  three  weeks'  duration  with  spontaneous  rupture  of  abscess.  Pus  in 
spaces  marked  A  and  B,  Fig.  729a.  Patient  a  woman  aged  twenty-one  years.  (Foote's  "Mmor 
Surgery.") 

antisepsis  are  exceedingly  remote.  Even  the  most  extensive  injuries  of  the  hand 
may  be  made  to  heal  with  as  little  deformity  as  often  follows  a  simple  wound  in 
which  inflammation  and  suppuration  are  established. 


DEFORMITIES 


689 


.  When  the  tendons  are  divided,  either  in  the  forearm  near  the  wrist  or  in  the 
palm  or  along  the  fingers,  it  is  essential  that  the  divided  ends  be  stitched  together 
with  silk  sutures.  When  there  is  loss  of  substance  the  ends  should  be  united  by 
a  long  linen  or  silk  loop  (Foote)  (Fig.  7."38a).  Cocaine  anaesthesia  and  Esmareh's 
bandage  should  be- employed. 

Deformities  of  the  hand  and  fingers  also  result  from  exostosis  and  new  forma- 
tions of  cartilage  in  the  digits.  Amputation  is  indicated  in  the  latter  condition, 
while  in  exostosis  j-elief  may  be  obtained  l)y  direct  incision  and  removal  of  the 
oitending  bone. 

Phlegmon  of  the  Hand  and  Fingers. — Phlegmon  of  the  fingers  is  an  exceed- 
ingly painful  afEection.  Occurring,  as  it  usually  does,  in  the  terminal  phalanx, 
a  knowledge  of  the  arrangement  of  the  fascia  here  is  essential  to  proper  treatment. 
Fig.  729  shows  the  intimate  attachment  of  the  connective-tissue  fibers  to  the  integu- 
ment of  the  palmar  aspect  of  the  digit  and  to  the  matrix  of  the  nail,  the  separation 
■of  the  various  layers  to  form  spaces  in  which  are  contained  quantities  of  fat.  The 
general  convergence  of  these  bundles  of  connective  tissue  toward  the  center  is  well 
illustrated  in  the  cut.  They  are  intimately  attached  to  the  sheath  of  the  tendon  in 
front  and  to  the  periosteum  posteriorly.  The  lymph-channels  follow  the  layers 
of  fascia  from  the  skin  toward  the  bone.  Phlegmon  of  the  finger  ("  felon,"  or 
"  whitlow  ")  may  originate  in  the  bone  or  periosteum,  but  most  frequently  begins 
in  the  soft  tissues  (Fig.  729a).  On  account  of  the  arrangement  of  the  fascia  and 
lymphatics,  the  inflammation  rapidly  extends  to  the  tendon  or  jjeriosteum.  The 
dense  structure  of  the  tissues  here,  which  prevents  their  yielding  to  the  pressure 
of  the  inflammatory  infiltration,  Avill  account  for  the  unusual  degree  of  pain 
present  in  this  afEection.  In  paro- 
nychia (Fig.  729&),  where  the  skin 
and  matrix  of  the  nail  are  involved, 
there  is  less  pain  and  tension. 


Tig.  730. — Showing  by  injection  the  continuity 
of  the  synovial  sheaths  of  the  little  finger  and 
thumb  with  the  large  sac  beneath  the  palmar 
fascia.     (After  A^ogt.) 


Fig.  731. — Showing  aX  A  A  A  the, sheaths  of  the 
ring,  middle,  and  index-fingers  ending  in 
blind  extremities  toward  the  palmar  sac. 
(After  Vogt.) 


Phlegmon  of  the  palmar  aspects  of  the  thumb  or  little  finger,  not  relieved  by 
■early  incision  and  disinfection,  maj'  extend  along  the  sheaths  of  their  tendons  and 
invade  the  entire  palmar  fascia.  Conversely,  central  phlegmon  of  the  palm  of  the 
hand  may  radiate  to  these  digits  (Fig.  730). 

By  reason  of  the  anatomical  arrangement  of  the  sheaths  of  the  ring,  index-, 
.and  middle  fingers,   closing   as  they   do   in  blind   extremities   at  the  metacarpo- 


690  ■  DEFORMITIES 

phalangeal  articulations,  the  inflammatory  jDrocess  does  not  extend,  as  a  rule,  into 
the  large  synovial  sac  beneath  the  jjalmar  fascia  (Figs.  730  and  731).  Upon  the 
back  of  the  hand  and  fingers  phlegmon  behaves  as  it  does  beneath  the  skin  in 
other  parts  of  the  body. 

In  the   treatment  of  ivhitlow  the  first  indication  is  to  relieve  tension  at  the 
earliest  moment   by  puncture  or  incision.     The  exact  point  of  inflammation  in 


Fig.  731a. — Phlegmon  of  finger  with  abscess  developing  in  tlie  course  of  the  lymphatic  vessel.  The 
arrows  are  directed  to  these  points.  Note  the  different  appearance  of  tuberculosis  as  shown  in 
Fig.  7316  and  in  the  late  stages  of  syphilitic  infection  as  shown  in  Fig.  731c.  (Foote's  "Minor 
Surgery.") 

the  earliest  stage  of  phlegmon  may  be  recognized  by  direct  pressure  with  a  small 
pointed  instrument,  as  a  probe  or  director.  Cocaine  may  be  utilized  to  prevent 
pain  when  the  incision  is  made.    A  rubber  ligature  tied  around  the  finger  to  arrest 


^  Tig.  7316. — Tuberculosis  of  flexor  tendon  sheaths  of  hand.       Especial  distention  of  sheath  of  middle 
1  finger;  sinus  in  palm.     Patient  a  boy  aged  six  years.      (Foote's  "Minor  Surgen,'.") 

the  circulation,  and  a  few  minims  injected  into  the  line  of  incision,  will  deaden 
all  sensibility.     The  incision  should  be  free,  and  down  to  the  tendon  or  bone,  to 


DEFORMITIES 


691 


insure  relief  of  all  tension.  The  part  slioiild  then  be  submerged  in  warm  sub- 
limate solution,  the  ligature  removed,  and,  after  a  minute  or  two  of  bleeding  under 
water  an  iodoform  strip  should  be  packed  into  the  wound,  and  a  moist  aseptic 
dressing  applied. 

When  pus  has  formed  and  can  be  evacuated  in  this  manner,  the  opening  should 
be  made  upon  the  lateral  aspects  of  the  finger,  in  order  to  avoid  the  sheath  of 
the  tendon. 

In  phlegmon  beneath  the  palmar  fascia  the  same  principles  of  incision  and 
drainage  should  be  applied,  avoiding  the  larger  vessels  when  possible. 

» When  amputation  of  the  finger  is  necessitated  it  is  in  general  advisable  to 
preserve  the  end  of  the  metacarpal  bone,  thus  securing  a  broader  palmar  surface 
(Fig.  731d). 

Ganglion. — Ganglion  is  due  to  the  localized  collection  of  a  variable  quantity  of 
synovial  fluid  in  the  sheaths  of  the  tendons,  or  bursEE  on  the  dorsum  of  the  hand 


Fig.  731c. — Syphilis  of  left  wrist,  left  forefinger  and  right  ring-finger,  eoiimieiicuif;  one  ,\  luf  ago  in  the 
ring-finger,  a  part  of  which  was  amputated  by  a  physician.  Patient  a  woman  aged  thirty-six  years. 
(Foote's  "Minor  Surgery.") 


or  wrist.  Excision  and  dissection  under  cocaine  antesthesia,  and  strict  asepsis,  I 
have  found  to  be  the  most  satisfactory  means  of  effecting  a  cure.  They  may  be 
made  to  disappear  by  absorption,  after  subcutaneous  rupture  from  a  sharp  blow 
with  the  back  of  a  book  or  padded  hammer. 

Division  of  the  tendons  of  any  part  of  the  hand  or  of  the  wrist  near  the  hand 
demands  careful  asepsis  and  immediate  suture  of  the  tendons  and  nerves,  if  these 
be  divided.  When  the  wound  is  across  the  wrist,  the  skin  should  be  freely  dis- 
sected back  in  order  to  thoroughly  expose  the  tendons,  which  usually  are  consider- 
ably retracted  in  the  direction  of  the  origin  of  the  muscle;  it  also  requires  a 
thorough  knowledge  of  anatomy  in  order  to  separate  the  various  tendons  and  to 
unite  the  upper  section  to  the  proper  tendon  of  insertion.  I  employ  fine  sterile 
silk  sutures,  using  two  tlireads  to  each  tendon,  and  an  additional  thread  when  the 
tendon  is  imusually  broad  or  strong,  such  as  the  flexor  carpi  ulnaris.  The  needle 
is  passed  entirely  through  the  tendon  between  one  eighth  and  one  fourth  of  an  inch 
from  the  divided  edge.  All  sutures  are  inserted  and  approximation  made  grad- 
ually with  the  hand  and  arm  in  a  position  which  will  most  thoroughly  relax  the 
tissues  to  be  approximated.     N'erve  suture  has  been  described.     It  is  important 


692 


DEFORMITIES 


in  uniting  such  a  nerve  as  the  median  or  ulna  at  the  wrist,  to  use  fine  needles,  a 
round  one  preferably,  which  will  not  cut  the  nerve  fibers,  and  when  tension  is  great 

to  pass  one  needle  and  suture  through 
the    center    of    the   nerve    about    one 


Fig.  732. — Showing  outline  relation  of  arter- 
ies, and  line  of  incision  which  may  avoid 
the  more  important  vessels.      (After  Vogt.) 


Pig.  731rf.  —  Aiupiitatiuu  tliruuf;li  the  metacarjoo- 
phalangeal  joint.  The  iDliotograph  taken  some 
3'ears  later,  shows  the  permanent  wide  gap  be- 
tween the  remaining  fingers  and  the  broad  palmar 
surface  which  is  lost  when  the  end  of  the  meta- 
carpal bone  is  removed.  (Foote's  "Minor  Sur- 
gery.") 


eighth  of  an  inch  from  the  cut  sur- 
face ;  then  on  either  side  of  this  to 
insert  a  very  delicate  suture  into  the 
sheath  of  the  nerve.  Approximation 
should  be  very  carefully  made,  not 
jamming  the  ends  of  the  nerve  together,  but  securing  them  snugly  in  opposition. 
The  dressing  should  consist  of  sterile  gauze  with  plaster  of  Paris  over  all,  the  hand 
being  held  properly  flexed  for  six  or  eight  weeks  after  the  operation.     The  nerves 


Fig.  732a. — Ganglion  of  the  wrist.     Lateral  view  to  show  the  elevation  of  the  tumor. 
(Foote's  "Minor  Surgery.") 

reunite  in  from  two  to  six  weeks.  Function  may  not  always  be  early  established, 
and  in  some  instances  months,  and  as  much  as  two  years,  have  elapsed  before  con- 
ductivity was  restored. 


CHAPTER   XXXIII 

THE     SPINAL     COED  ^     AND     ITS     MEMBRANES THE     NERVES  ^ THE     MUSCLES     AND 

TENDONS 

The  traumatic  lesions  of  the  cord  are  classified  as  concussion,  contusion,  pene- 
trating wounds,  hfemorrhage,  extra-  or  intra-dural,  or  in  the  substance  of  the  cord 
proper,  together  with  the  various  lesions  of  compression,  or  of  partial  or  complete 
division  which  may  follow  dislocations  or  fractures  of  the  vertebrce. 

The  idiopathic  lesions  are  congenital  and  acquired.  The  chief  congenitive 
lesion  is  spina  bifida.  Tuberculosis,  affecting  either  the  bones  of  the  spinal  column 
or  the  meninges,  is  the  most  frequent  of  the  acquired  lesions.  In  addition  to  these 
are  the  various  neoplasms  or  tumors,  and  certain  infective  processes,  as  meningitis. 

Concussion  of  the  spine  is  defined  surgically  as  a  partial  or  complete,  temporary 
or  permanent  loss  of  function  without,  so  far  as  has  yet  been  demonstrated,  the 
presence  of  any  recognizable  anatomic  changes  in  the  minute  or  gross  structure 
of  the  cord. 

In  contusion  there  are  the  same  symptoms  as  in  concussion,  usually  more  pro- 
nounced, but  here  there  is  found,  to  account  for  loss  of  function,  extravasation  of 
blood  from  the  capillaries  of  the  cord  substance,  or  from  the  peripheral  blood 
supply,  with  pressure,  and  at  times  division  of  cord  substances. 

The  symptoms  of  contusion  and  concussion  are  therefore  clinically  considered 
as  the  same. 

Penetrating  loounds  are  chiefly  gunshot  or  knife  injuries.  The  former  usually 
cause  comminution  or  limited  fracture  of  bone,  carrying  with  the  missile  spiculse, 
which  may  be  buried  in  the  membranes  or  cord.  Division  of  the  cord  as  the  result 
of  these  injuries  produces  paralysis,  which  is  permanent,  and  which  is  referable  to 
all  parts  of  the  body  to  which  the  nerve  fibers  or  nerve  cells  so  injured  are  func- 
tionally related.  The  track  of  punctured  or  stab  wounds  of  this  organ  is  usually 
through  the  intervertebral  spaces,  and  they  are  most  frequently  met  with  in 
the  neck. 

Hamorrhage  within  the  spinal  canal  may  in  rare  instances  occur  spontaneously. 
It  is,  however,  in  practically  all  eases  of  traumatic  origin. 

Dislocation  and  fractures  of  the  vertebrae  are  apt  to  occur  together,  although 
one  or  the  other  may  exist  alone.  They  are  caused  by  a  direct  blow,  or  indirectly, 
as  by  fall  upon  the  buttocks,  or  by  diving,  striking  upon  the  head,  or  in  over- 
flexion  or  extension.  The  cervical  region  is  oftener  the  seat  of  these  injuries. 
Fracture  or  dislocation  of  the  atlas  has  been  reported  without  symptoms  of  spinal 
cord  injury.^  The  chief  symptom  connected  with  the  injury  of  the  spinal  cord  is 
paralysis  of  motion  or  of  sensation.  The  sensory  symptoms  may  be  those  of  anaes- 
thesia, or  at  times  of  hyperfesthesia.  There  may  be  a  noticeable  displacement  of 
the  spines,  and  in  the  cervical  region  interference  with  swallowing,  due  to  pressure 
upon  the  oesophagus. 

'  Surgically  the  spinal  cord  may  be  considered  as  extending  from  the  occipito-atloid  articula- 
tion to  the  upper  surface  of  the  second  lumbar  vertebra. 

2  For  many  valuable  suggestions  used  in  this  chapter,  from  "Neurological  Surgery,"  pub- 
lished in  "Surgery,  Gynsecology,  and  Obstetrics,"  for  April,  1907,  the  author  is  indebted  to  Prof. 
John  B.  Murphy. 

3  Br.  H.  A.  Wilson  reports  the  case  of  a  man  who  suffered  a  fracture  of  the  odontoid  process 
and  a  forward  dislocation  of  the  atlas  as  clearly  demonstrated  by  the  radiograph.  There  was  no 
paralysis;  the  patient  was  unable  to  sleep  lying  down,  but  could  do  so  sitting  up  with  his  head 
resting  forward  on  a  pillow;  occasionally  he  had  difficulty  in  swallowing  because  of  the  mechanical 
pressure  of  the  displaced  bone  on  the  oesophagus. 

693 


694      THE   SPINAL  CORD— THE   NERVES— THE   MUSCLES  AND   TENDONS 

Treatment. — The  chief  indication  in  treatment  is  relief  of  compression.  If 
the  cord  has  been  divided,  restoration  of  fimction  never  takes  place.  Compression 
from  clot,  the  presence  of  a  foreign  l:)ody,  or  a  displaced  particle  of  bone  will, 
however,  produce  paralysis  when  no  cord  elements  are  divided.  The  knowledge 
of  this  fact  makes  it  imperative,  unless  extraordinary  conditions  contra-indicate  it, 
to  perform  laminectomy,  if  for  no  more  than  an  exploratory  procedure.  Properly 
conducted,  this  operation  is  not  dangerous,  and  it  gives  the  one  opportunity  of 
removing  pressure  and  preserving  the  cord  from  degenerative  changes  which  may 
be  permanent  if  the  compression  is  not  soon  moved.  The  technic  of  laminectomy  is 
given  on  another  page.^ 

Hwmorrhage. — In  the  diagnosis  of  a  suspected  haemorrhage,  lumbar  puncture 
should  be  done.  When  pain  is  felt  with  this  lesion,  it  is  usually  paroxysmal  and 
burning  in  character,  and  may  or  may  not  be  accompanied  by  muscular  spasm. 
1 .  Tuberculosis  of  the  bones  of  the  spinal  column  is  considered  in  another  chap- 
ter. Aggregations  of  tuberculous  material,  connected  or  not  with  breaking  down 
of  the  bodies  of  the  vertebras,  at  times  press  upon  the  dura  or  the  cord,  so  as  to 
cause  partial  or  complete  hemiplegia,  or,  more  commonly,  paraplegia.  Laminec- 
tomy is  indicated  as  soon  as  this  condition  is  recognized,  and,  taken  early  enough, 
will  relieve  the  pressure  symptoms  with  more  or  less  restoration  of  function." 
When  the  laminaa  are  removed,  if  the  tumor  is  within  the  dura  it  should  be  opened 
carefully  in  the  middle  line,  as  elsewhere  directed,  and  the  tuberculous  materials 
carefully  scraped  from  the  cord  with  a  dull  spoon  or  curette.  In  connection  with 
the  surgical  treatment  of  the  spinal  column  or  cord  for  tuberculosis,  the  most 
thorough  climatic  and  nourishing  treatment  should  be  combined.  Proper  support 
should  be  given  to  any  functional  weakness  of  the  muscles  or  bones. 

Neoplasms  of  the  spine  may  be  divided  into  those  developed  in  the  vertebrse, 
which  are  common  to  bones  in  general,  and  which  produce  paralysis  by  compression, 
and  those  originating  directly  in  the  cord  or  in  its  membranes. 

Those  of  the  meninges  maj^  be  considered  as  extra-  and  intra-dural.  The  usual 
varieties  are  lipoma,  sarcoma,  carcinoma,  and  inyxoma,  while  occasionally  a  cyst 
caused  by  the  echinococcus  is  observed. 

The  symptoms  of  these  various  tumors  are  chiefly  those  of  compression,  either 
upon  the  cord  proper,  or  the  motor  or  sensory  roots  of  the  nerves  given  ofE  from 
it.  The  location  of  the  tumor  is  estimated  usually  as  about  four  inches  higher 
than  the  level  of  the  sensory  disturbance  on  the  back  (Starr). 

Tumors  of  the  cauda  equina  may  be  suspected  when  there  is  pain  in  the  sacral 
region  radiating  to  the  leg,  interfering  more  or  less  with  the  function  of  the 
bladder  and  the  rectum,  but  more  particularly  producing  muscular  weakness  in 
the  lower  extremities. 

The  indications  in  all  of  these  various  lesions  are  to  operate  early  for  the  relief 
of  compression. 

Spina  bifida  is  a  condition  resulting  from  the  failure  of  development  in  the 
laminse  and  spines  in  one  or  more  of  the  vertebrae.  Prof.  Charles- L.  Dana  classi- 
fies the  varieties  of  spina  biiida  as  follows : 

(a)  Meningocele;  a  protruding  sac  composed  of  meningeal  membranes  and 
cerebrospinal  fluid  only.  This  may  be  either:  1,  Anterior,  abdominal,  or  pelvic; 
or  2,  posterior  or  dorsal  tumor. 

(b)  Meningom5'elocele ;  hydromyelia;  a  tumor  composed  of  meningeal  mem- 
branes, cerebrospinal  iiuid,  and  spinal  cord,  including  cauda. 

(c)  Syringomyelocele;  composed  of  meninges,  cerebrospinal  fluid,  and  spinal 
cord,  with  an  enormous  dilatation  of  the  central  canal. 

To  these  Prof.  John  B.  Murphy  adds  the  rare  form  spina  bifida  occulta,  in 
which  there  is  a  cleft  of  the  spinal  column  without  any  visible  protrusion  of  the 
contents  of  the  canal. 

1  The  author  has  performed  this  operation  in  some  twenty  instances,  and  in  no  case  has  a 
fatality  followed  as  a  result  of  the  operation,  nor  has  the  permanent  removal  of  the  laminse  and 
spines  of  three  contiguous  vertebrae  interfered  with  the  supporting  power  of  the  spinal  column. 

^  In  one  instance  in  the  experience  of  the  author  a  complete  jsaraplegia  of  several  months 
entirely  disappeared  after  laminectomy,  opening  the  dura  and  removing  the  tuberculous  mass 
from  the  posterior  surface  of  the  cord. 


THE   SPINAL   CORD— THE   NERVES— THE   MUSCLES  AND  TENDONS      695 

In  meningocele  the  cord  elements  may  be  intact,  wliile  in  meningomyelocele 
they  are  involved  in  the  tumor  and  are  very  frequently  spread  out  and  fused  with 
the  posterior  and  median  surface  of  the  sac,  forming  a  part  of  the  cyst  wall. 

In  syringom3'elocele  there  is  usually  a  pressure  atrophy  of  the  cord,  with  partial 
or  complete  paraplegia. 

Spina  bifida  is  met  with  most  frequently  in  the  lumbo-sacral  region,  next  in 
frequency  in  the  neck,  rarely  elsewhere.  One  fissure  may  exist  below  and  one 
above  in  the  same  child,  though  it  is  very  rarely  multiple. 

The  tumor  may  vary  in  size  from  one  inch  to  six  or  eight  inches  in  the  longest 
diameter,  and  may  be  sessile  or  pedunculated.  It  is  elastic  to  the  touch,  and  when 
covered  by  the  integument,  this  is  thinner  than  normal.  The  skin  is  oftener  want- 
ing over  the  mass,  the  protruding  dura  mater  forming  the  outside  covering. 

The  character  of  the  swelling  may  be  recognized  by  its  congenital  origin,  its 
location  in  the  median  line  of  the  back,  almost  always  in  the  lumbo-sacral  region, 
its  smooth  contour,  elasticity,  and  chiefly  by  its  variable  size.  It  becomes  larger 
and  more  tense  during  the  act  of  crying,  and  by  pressure  its  contents  may  in  part 
be  forced  back  into  the  spinal  canal  and  ventricles  of  the  brain.  Con^nilsive  move- 
ments may  follow  too  great  and  prolonged  compression  of  the  tumor.  The  prog- 
nosis is,  as  a  rule,  very  unfavorable.  Ulceration  of  the  integument  over  the  mass, 
followed  by  rupture  of  the  sac,  is  apt  to  occur,  usually  ending  in  death.  A  recovery 
after  this  accident  is  rare,  although  such  cases  are  reported.  Or  the  tumor  may 
remain  indefinitely  in  about  the  same  condition  as  at  birth.  Paralysis,  more  or 
less  complete,  in  the  lower  extremities  is  the  rule. 

The  treatment  will  depend  in  large  measure  upon  the  location  and  character 
of  the  tumor.  When  the  fissure  is  small  and  the  tumor  is  pedunculated,  the  cord 
elements  not  being  prolapsed  or  in  any  way  involved  (meningocele),  a  cure  may 
be  effected  by  ligation  at  the  level  of  the  skin.  In  a  case  of  this  character  situ- 
ated in  the  cervical  region,  the  author  successfully  performed  this  operation  with 
complete  cure,  and  without  any  subsequent  paralysis.  In  the  large  majority  of 
cases  of  spina  bifida  the  more  radical  procedure  of  removal  of  the  sac  by  dissection, 
covering  in  the  cord  by  a  plastic  skin-flap  operation  is  indicated.  The  prognosis 
is  in  general  grave,  both  as  to  a  fatal  and  functional  result.  The  treatment  by 
injections  should  not  be  considered.  In  the  radical  operation  the  dissection  should 
begin  from  the  lateral  aspects  of  the  tumor,  for  the  reason  that  the  cord  elements 
are  apt  to  be  attached  near  the  median  line.  Approached  from  the  side,  they  are 
more  easily  recognized,  and  may  be  preserved  by  being  enclosed  in  the  new  canal 
formed  by  suture  of  the  membranous  and  cutaneous  flaps  from  the  sides. 

The  Nerves. — Partial  and  complete  loss  of  conductivity  in  a  nerve,  or  excessive 
pain,  is  not  infrequently  caused  by  changes  in  the  nerve  sheath  or  in  the  neuri- 
lemma. These  new  formations  belong  to  the  connective-tissue  variety,  and  may 
or  may  not  be  malignant.  They  form  perceptible  enlargements,  which  are  usually 
fusiform  or  spindle-shaped,  and  may  often  be  recognized  by  palpation.  The  author 
has  operated  upon  three  cases  of  this  character  connected  with  the  cervico-brachial 
plexuses.  In  two  of  these  complete  extirpation  was  made  of  all  the  nerve  divisions 
involved,  which  relieved  the  painful  symptoms  entirely,  but  resulted  in  permanent 
paralysis  in  the  distribution  of  the  nerves  removed.  In  the  second  case,  on  account 
of  extreme  pain  and  to  prevent  the  acquirement  of  the  morphine  habit,  an  opera- 
tion was  undertaken  which  necessitated  the  surgical  division  of  the  clavicle.  There 
were  two  separate  tumors  of  the  cervico-brachial  plexus,  from  one  half  to  one  inch 
in  diameter  at  their  largest  portion,  tapering  gradually  four  or  flve  inches  toward 
the  axilla  and  up  into  the  neck.  On  account  of  the  extensive  paralysis  which 
would  necessarily  follow  excision,  the  operation  was  discontinued,  and  the  collar 
iDone  arched  upward  in  such  a  way  as  to  relieve  pressure.  The  collar  bone  united 
in  the  new  position,  and  the  pain  was  entirely  relieved.  Ten  years  later  the  patient 
was  in  perfect  healtli,  with  the  exception  of  a  very  slight  deformity  caused  by  the 
elevated  collar  bone  and  the  neoiilasms,  which  are  still  appreciable. 

As  soon  as  a  neuroma  is  recognized  the  nerve  should  be  divided  above  and 
Ijelow  the  tumor  at  a  sufficient  distance  to  be  safely  in  sormd  tissue  and  immediate 
reunion  efl:ected.     The  element  of  pain  should  also  be  considered  as  an  indication 


696      THE   SPINAL   CORD— THE   NERVES— THE   MUSCLES   AND  TENDONS  ; 

for  suro-ical  relief.  When  a  nerve  has  been  divided,  or  has  been  destroyed  by 
pressure,  excision  of  the  degenerated  or  diseased  stumps  should  be  practiced,  and 
end-to-end  suture  immediately  performed.  When  ununited,  the  distal  end  begins- 
at  once  to  take  on  a  swollen  and  bulblike  appearance,  with  commencing  degenera- 
tion, which  extends  rapidly  toward  its  distribution.  On  the  central  end  the  same 
change  takes  place  in  lesser  degree.  In  suturing  a  nerve  the  finest  linen  or  silk 
or  jSTo.  0  chromicized  catgut  should  be  employed.  On  account  of  the  firmer  and 
better  holding  power  of  the  former  it  is  preferred.  In  reuniting  a  nerve  not  only 
should  the  bulbous  ends  be  removed,  cutting  squarely  across  where  the  fibers  are 
normal,  but  any  cicatricial  tissue  or  neighboring  adhesions  should  be  removed. 
Asepsis  is  imperative,  since  infection  and  the  presence  of  sear  tissue  will  retard 
or  prevent  restoration  of  function.  A  perfectly  round  and  partly  curved  needle 
of  the  smallest  practical  size  shoiild  be  used.  The  sutures  are  introduced  only 
through  the  sheath  about  one  eighth  of  an  inch  from  the  edge,  and  come  out  be- 
neath it  at  the  free  end,  care  being  taken  that  the  needle  does  not  dip  down  among 
the  nerve  bundles.  On  a  small  nerve  one  of  these  sutures  on  opposing  surfaces 
may  suffice,  while  in  the  larger  trunks  four  or  more  are  required.  Where  there 
is  difficulty  in  approximation,  one  or  two  sutures  may  be  passed  through  both 
sheath  and  nerve  substance,  to  be  used  as  tension  sutures.  In  a  case  in  which  the 
great  sciatic  nerve  had  been  divided  just  at  the  bifurcation,  this  operation  was 
successfully  performed.  One  of  the  tension  sutures  passed  through  the  middle 
of  the  external  popliteal,  the  other  through  the  internal,  while  both  of  them  passed 
through  the  main  trunk. 

Even  ■niien  the  ends  do  not  meet  by  a  half  inch  or  more,  such  is  the  repro- 
ductive and  regenerative  power  of  some  of  the  nerves  that  if  they  be  held  steadily 
in  place  by  long  sutures  and  are  embedded  in  contiguous  muscle  substance  and 
kept  perfectly  at  rest  for  a  proper  period  of  time  (about  two  months),  reproduc- 
tion with  functional  restoration  may  occur.  The  first  symptom  of  return  of 
function  is  a  change  in  the  nutrition  of  the  part  affected,  with  the  healing  of 
trophic  ulcers  when  these  are  present,  then  sensation,  and  lastly  motion.  Some- 
times motion  does  not  return  for  several  months  after  a  successful  union  has  been 
accomplished. 

In  the  paralysis  resulting  from  anterior  poliomyelitis,  nerve  transplantation 
is  worthy  of  consideration,  especially  when  a  small  group  of  muscles  is  involved. 
The  operation  should  be  done  early  in  life,  from  the  sixth  month  to  the  third 
year,  and  in  general  should  be  supplemented  by  tendon  implantation,  carrying  all 
or  part  of  the  tendon  of  a  live  muscle  over  to  one  that  is  paralyzed.  At  times 
the  shortening  of  the  paralyzed  and  overstretched  tendons,  which  cannot  be  rein- 
forced by  a  live  tendon,  is  advisable.  In  transplanting  the  peripheral  end  of  a 
dead  nerve  into  the  side  of  a  live  nerve,  it  is  important  that  the  nerve  fibers  should 
be  placed  in  close  end-to-end  apposition  with  those  of  the  nerve  which  is  still 
functionating. 

Nerve  stretcliing  is  recommended  in  the  treatment  of  persistent  neuralgia,  and 
in  a  certain  proportion  of  eases  gives  at  least  temporary  relief.  These  operations 
may  practically  all  be  done  with  cocaine  ansesthesia.  In  sciatica,  in  which  disease 
it  is  most  frequently  recommended,  exposure  of  the  trunk  is  readily  made  between 
the  trochanter  major  and  the  tuberosity  of  the  ischium.  Should  it  be  necessary 
after  the  exposure  of  the  nerve  by  cocaine,  the  stretching  may  be  done  under 
momentary  nitrous-oxide  ansesthesia. 

Muscles  and  Tendons. — Of  the  surgical  lesions  of  the  muscles,  contusions,  rup- 
ture, and  penetrating  wounds  are  the  most  common.  In  contusions,  in  general, 
nothing  more  is  required  than  to  support  the  injured  muscle  or  group  of  muscles 
by  appropriate  bandaging  with  a  splint,  if  necessary,  and  permitting  careful  passive 
motion  in  order  to 'prevent  adhesions  in  the  process  of  repair. 

AVhen  a  muscle  is  torn,  if  the  injury  is  extensive  and  the  function  of  the  organ 
is  seriously  impaired  by  the  separation  of  its  fibers,  an  anaesthetic  should  be  ad- 
ministered and  careful  suture  made  of  the  torn  ends.  The  material  best  adopted 
for  suture  is  a  celluloiden  linen  for  the  muscular  sheath,  with  ten-day  catgut  sutures 
for  the  muscle  bundles.     As  these  are  buried  sutures,   the  most   careful  asepsis 


THE  SPINAL  CORD— THE   NERVES— THE  MUSCLES   AND  TENDONS      697 

should  be  practiced.  The  fixation  should  be  in  that  position  which  will  give  the 
most  complete  relaxation  and  rest  to  the  injured  member. 

Muscles  which  with  their  tendons  are  occasionally  dislocated  demand  only  re- 
position and  careful  holding  in  position  by  bandage  or  splint  until  a  cure  is  effected. 
Hernia  of  a  muscle,  in  which  some  of  the  fasciculi  protrude  through  the  sheath, 
or  the  fascia  or  skin  is  rare  and  requires  no  special  consideration. 

Muscular  neuralgia,  so-called,  is  in  all  probability  due  to  some  general  condi- 
tion of  the  system  (uric-acid  or  oxalic-acid  diathesis),  or  to  the  exposure  of  a 
limited  area  of  the  body  to  sudden  changes  in  temperature.  Many  cases  of  so-called 
myalgia  are  in  reality  neuralgia. 

A  painful  condition  of  the  muscles  is  present  in  certain  forms  of  toxaemia,  as 
in  lead-poisoning,  in  the  so-called  gonorrhceal  rheumatism,  in  syphilitic  infection 
and  tuberculosis,  and  also  in  the  deposit  of  calcareous  or  inorganic  substances  in 
the  muscle  substance,  usually  near  the  junction  with  their  tendons  or  aponeuroses. 
These  calcareous  deposits  are  sometimes  converted  into  bone  (myositis  ossificans). 
A  rare  muscular  lesion  is  hydatid  cyst  due  to  the  presence  of  the  ova  of  the  tape- 
worm. It  requires  no  special  treatment  except  incision  and  removal  of  the  contents 
by  drainage. 

The  treatment  in  each  of  these  varieties  of  muscular  lesion  must  of  necessity 
be  directed  to  the  prevailing  dyscrasia.  The  elimination  of  iiric  and  oxalic  acid 
may  be  best  effected  by  rigid  and  simple  diet  combined  with  thorough  irrigation 
of  the  tissues  by  the  free  imbibition  of  water,  by  massage,  judicious  exercise  and 
open-air  life.  A  warm  climate  is  advisable  in  order  to  aid  elimination  in  keeping 
the  pores  of  the  skin  freely  open. 

Muscular  paralyses,  in  addition  to  constitutional  and  operative  measures,  di- 
rected toward  the  primary  cause,  may  require  surgical  intervention. 

In  the  choice  of  orthopedic  or  supporting  apparatus,  massage,  and  at  times 
nerve  or  tendon  transplantation — that  is,  the  carrying  of  a  part  or  all  of  a  live 
nerve  and  suturing  it  to  a  dead  one,  or  a  tendon  of  a  live  muscle  and  uniting  it 
to  the  tendon  of  one  that  is  paralyzed — is  employed.  These  procedures  should 
not  be  undertaken  until  a  most  careful  study  is  made  of  the  condition  of  the  organs 
involved. 

In  correcting  the  deformity  due  to  partial  or  complete  paralysis  of  one  or  more 
of  a  group  of  muscles,  it  not  infrequently  becomes  necessary  to  elongate  by  division 
the  tendons  of  the  contractured  group,  or  to  shorten  the  tendons  of  the  over- 
stretched or  paralyzed  organs.  Tendon  division  is  a  simple  procedure,  and  when 
it  can  with  perfect  safety  he  effected  subcutaneously,  this  should  be  done.  How- 
ever, with  careful  asepsis  there  is  no  objection  to  an  incision  which  will  expose 
the  tendon,  and  this  should  be  done  when  it  lies  in  close  contact  with  a  nerve  or 
vessel  which  otherwise  might  be  injured.  In  shortening  tendons,  as  a  rule,  over- 
lapping and  careful  suture  with  fine  linen  will  suffice. 

In  lengthening  a  tendon,  the  method  most  generally  employed  is  to  cut  half- 
way through  the  tendon  at  a  given  point,  split  it  in  its  long  axis  for  the  required 
length,  and  complete  the  section  by  dividing  the  half  opposite  to  that  which  was 
first  incised,  and  then  uniting  the  two  free  ends  by  end-to-end  anastomosis. 

The  lesions  of  the  tendons  which  most  interest  the  surgeon  are  those  associated 
with  contractions  of  the  fascia  of  the  hand  and  of  the  foot,  or  to  cicatricial  con- 
ditions resvdting  from  extensive  injuries,  burns,  etc.,  and  the  more  common  lesions 
connected  with  disease  of  the  sheaths  of  the  tendons.  Dupuytren's  contraction  is 
given  in  the  chapter  on  deformities,  together  with  the  various  lesions  of  the 
bursas. 


CHAPTER    XXXIV 

KEOPLASMS     (ICEW    GROWTHS,    TUMOKS) 

A  NEOPLASM  is  a  non-inflammatory  mass,  composed  of  new-formed  elements 
luhicli,  having  their  type  in  the  normal  embryonic  or  adult  tissues,  are  dependent 
upon  these  for  nutrition,  and  yet  are  not  amenahle  to  the  laws  regulating  and 
limiting  the  development  of  the  normal  striiclurcs. 

The  efforts  at  classification  of  new  growths  ui^on  a  liistological  basis  have  not 
been  generallj^  satisfactor}'.  Virchow,  Foerster,  Corni.l  and  Eanvier,  and  other 
pathologists,-  with  the  same  end  in  view,  have  arrived  at  conclusions  scarcely  recon- 
cilable. A  discussion  of  these  various  classifications  belongs  more  properly  to 
special  works  on  pathology.  Clinicall}'-,  they  admit  of  division  into  two  heads — 
the  malignant  and  non-malignant} 

Malignancy  in  a  tumbr  means  its  tendencj'  to  become  multiple  by  metastasis; 
the  tendency  of  the  elements  of  which  it  is  composed  to  travel  along  the  lymph 

■  The  following  classification  of  tumors  is  taken  from  ''Modern  Surgery,"  by  Prof.  Roswell 
Park,  published  by  Lea  Brothers  &  Company,  Philadelphia,  1907,  to  which  work  the  student  is 
referred. 

1.  Retention  Cysts 

Types. — Hydronephrosis,  hydrocholecyst,  due  to  obstruction  of  the  ureter  or  gall  duct. 

Tubulo-cysts,  found  in  the  vitello-intestinal  duct,  connected  with  the  remains  of  the  Wolffian 
body,  allantoic,  etc. 

Hydroceles,  watery  fluid  collected  in  a  previously  existing  serous  cavity;  tunica  vaginalis, 
tunica  funiculi;  canal  of  Nuck.     Hydroceles  of  the  neck,  cystic  collections  of  congenital  origin. 

Glandular  cysts,  as  ranula. 

Pseudocysts,  intestinal  and  vesical  diverticula.  (Sutton.)  Synovial  cysts,  bursas,  gan- 
glion, etc. 

Accural  cysts,  found  in  the  brain  and  central  nervous  system.     (Sutton.) 

Hydatid  cysts,  due  to  the  ova  of  the  tape-worm.  Cysts  due  to  blood  extravasation,  hema- 
tocele, etc. 

2.  Dermoids 

Dermoids  are  cysts  or  tumors  containing  tissues  and  appendages  which  are  developed  from 
the  epiblast.  They  contain  skin,  hair  follicles,  sebaceous  glands,  sweat  glands,  teeth,  mucous 
membrane,  etc.     Sutton  divides  dermoids  into  three  classes: 

1.  Sequestration  dermoids,  due  to  coalescence  laetween  two  surfaces  possessing  an  epiblastic 
covering. 

2.  Tubulodermoids,  developing  from  obsolete  canals  and  ducts,  as  the  omphalomesenteric 
duct,  branchial  clefts,  etc. 

3.  Ovarian  dermoids  and  teratomas,  unilocular  or  multilocular  cysts  lined  with  epithelium 
containing  chiefly  mucoid  fluid.     (Park.)     In  large  tumors  of  this  type,  hair,  teeth,  etc.,  are  found. 

3.  Teratomas 

Tumors  composed  of  tissues  of  epiblastic  and  raesoblastic  origin,  probably  also  hypoblastic. 
They  form  irregular  tumors  containing  tissues  or  fragments  of  viscera  of  a  suppressed  foetus  which 
is  attached  to  an  otherwise  normal  individual. 

Embryonal  adenosarcoma  connected  with  the  renal  and  adrenal  structures.  They  are  con- 
genita!, usually  appearing  early  but  may  come  in  advanced  adult  life. 

4.  Tu.MORS  OF  Connective-Tissue  Type 

Lipoma,  or  tumor  composed  of  fat,  is  subdivided  into  subcutaneous,  subserous,  and  sub- 
synovial. 

Fibroma,  composed  of  fibrous  tii=sue  occurs  in  the  ovary,  uterus,  intestine,  gum  (epulis), 
nerve-sheaths,  skin,  etc.     Epulis,  keloid,  dermoids,  are  terms  restricted  to  tumors  which  proceed 

698 


NEOPLASMS  699 

or  blood  channel?,  and,  thus  disseminated,  to  reproduce  the  parent  tumor;  or  its 
tendency  to  invade  and  destroy  the  tissues  in  its  vicinity,  and  to  recur  in  loco 
after  extirpation.  r 

primarily  from  muscles,  tendons,  and  aponeuroses  or  from  ligamentary  and  periosteal  tissue. 
(Park.)     Psammoma  is  a  hard  fibroma  of  the  dura  mater. 

Chondroma,  composed  of  hyaline  cartilage  and  osteoma  or  tumor  of  bone. 

Exostoses  are  classified  by  Sutton  as  (1)  Ossification  of  tendons.  (2)  Subungual  exostoses. 
(3)  Exostoses  due  to  calcification  of  inflammatorj'  exudations.     (Myositis  Ossificans.) 

Sarcoma,  tumor  composed  of  immature  mesoblastic  or  embryonic  tissue  in  which  cells  pre- 
dominate over  intercellular  material.  (Park.)  They  are  classified  according  to  the  shape  of 
their  cells  and  their  disposition,  into  (a)  round-cell;  (6)  spindle-cell;  (c)  myeloid,  to  which  other 
varieties  are  added. 

(A)  Lympliosarcoina,  a  round-cell  sarcoma  in  which  there  is  a  delicate  meshwork  resembling 
that  of  lymph  nodes,  not  to  be  confounded  with  enlargements  nor  with  specific  granulomas  in- 
volving these  Isonphatic  structures. 

(B)  Spindle-cell  sarcoma,  the  cells  spindle-shaped,  running  in  all  directions.  The  largest 
spindle-cells  are  at  times  striated,  and  have  been  called  rhabdomyoma.  There  is,  however,  no 
tumor  of  striped  muscle  fiber. 

Alveolar  sarcoma,  a  rare  type,  the  cells  assuming  an  alveolar  arrangement. 

(C)  Myeloid  or  giant-cell  sarcoma,  the  cells  resembling  those  of  the  red  marrow  of  young 
and  growing  bone  containing  a  large  number  of  multinuclear  cells  being  involved  in  a  matrix  of 
spindle  or  round  cells.  They  occur  in  the  long  bones  and  epulis,  or  spongy  tumors  springing  from 
the  gums.     (Park). 

(D)  Osteosarcoma  or  sarcoma  of  the  specific  bone-forming  connective  tissue.  There  may  also 
be  a  true  osteofibroma.  These  are  to  be  distinguished  even  clinically  from  the  medullary  sarcomas, 
which  develop  within  the  bone  and  expand  it.     (Park.) 

(E)  Chondrosarcoma,  involving  the  stroma  of  cartilage,  or  the  specific  tissue  which  produces 
cartilage.  AVhite  fibrous  cartilage  is  found  throughout  the  tumor.  Chondrofibroma  is  also 
possible.     (Park.) 

(F)  Emlothelioma,  composed  of  endothelial  cells  which  line  the  Ijrniph  spaces,  met  with  most 
frequently  in  the  skin  of  the  face,  the  genital  glands,  the  bones,  the  lymph  nodes,  and  dura. 

(G)  Angeiosarcoma,  originating  from  the  adventitia  of  the  blood  vessels.  (1)  PeritheHomas 
met  with  especially  in  the  kidneys,  the  bones,  and  skin,  originating  in  the  perithelial  cells  between 
the  capillaries  and  the  perivascular  lymph  spaces. 

(H)  Cylindroma,  angeiosarcoma,  in  which  hyaline  changes  have  occurred. 

(I)  Melanosarcoma,  or  pigmented  sarcoma  deservedly  considered  most  malignant. 

Myxoma,  composed  of  mucous  tissue.  (1)  Polj'pi,  nasal,  etc.  (2)  Cutaneous,  may  be 
sessile,  or  pedunculated.     (3)  XeuromjTcoma,  a  mucoid  tumor  involving  nerve  trunks. 

Myoma,  composed  of  unstriped  muscle  fiber,  develops  only  in  this  tissue;  most  frequently 
found  in  the  uterus.  It  has  been  seen  in  the  oesophagus,  in  the  walls  of  the  stomach,  prostate, 
bladder,  and  skin. 

Angeioma.  (1)  Capillary,  mother's  mark,  or  port-wine  mark.  (2)  Cavernous,  involving  the 
veins.     (3)  Arterial,  or  cirsoid  (aneurism). 

Lym-phangeiom-a,  composed  of  Ijonph  vessels,  divided  into  three  varieties: 

(1)  TThe  lymphatic  ne^■us,  seen  during  childhood  in  the  tongue,  known  as  macroglossia.  (2) 
Cavernous  lymphangeioma  cysts.  (3)  LjTnph  cysts,  due  to  dilatation  of  the  lymph  vessels.  The 
lower  extremities  and  the  scrotum  and  labia  are  often  enormously  enlarged  (elephantiasis). 

5.  Tumors  of  Xerve  Elements 

Glioma,  a  malignant  tumor  developing  directly  from  actual  nerve  structures  or  that  of  the 
original  nerve  elements.     (Park.)     Found  in  the  brain,  cord,  and  optic  nerve. 

Xeuroma,  originating  from  the  structures  of  the  nerve  trunks. 

(1)  Plexijorm  neuroma,  involving  the  branches  of  a  nerve  distributed  to  a  particular  area 
(rare).  (2)  Malignant  neuroma,  a  sarcoma  of  the  nerve  structures.  Traumatic  neuroma  is 
often  seen  in  amputation  stumps. 

6.  The  Epitheli.\l  Tumors 

Odontoma.  (1)  Epithelial.  (2)  Follicular  (dentigerous  cysts).  (3)  Fibrous.  (4)  Cemen- 
toma.  (5)  Folhcular  (containing  immature  teeth).  (6)  Radicular,  developing  in  the  roots  of 
teeth.     (7)  Composite,  a  hard  growth  occurring  in  the  jaws,  made  of  enamel,  dentine,  and  cement. 

Papilloma  or  fibro-epithelioma.  (1)  Warts.  (2)  Villous,  found  in  the  bladder  and  kidney. 
(3)  Intracystic,  found  in  mammary  cysts.  (4)  Ovarian,  growing  luxuriantly  from  peritoneal 
surfaces,  contiguous  to  the  ovary.     (5)  Cutaneous  horns. 

Mucous  polypus,  an  epithelial  tumor  hanging  from  the  mucous  membrane,  most  commonly  the 
rectum. 

Goitre  (struma),  neoplasm  of  the  thjToid  body.  (1)  Struma  parenchymatosa  nodosa.  (2) 
Struma  fibrosa. 

Ovarian  cystoma.     (1)  Glandular.     (2)  Papillary. 

Adenoma  and  fibro-adenoma  are  the  abnormal  outgrowth  of  the  normal  secreting  apparatus 
of  a  gland,  occurring  in  the  mamms,  parotid,  thjToid,  liver,  and  mucous  membrane  of  the  bowels 
and  uterus,     .\denoma  occurs  frequently  in  sebaceous  glands.     (Park.)     (1)  Sebaceous  cysts  or 


700  NEOPLASMS 

The  malignant  neoi^lasms  are  grouped  under  two  headings — carcinoma  and 
sarcoma. 

The  non-malignant  are  as  follows :  lipoma,  fibroma,  myxoma,  osteoma,  enchon- 
droma,  angeioma,  neuroma,  myoma,  adenoma,  papilloma,  and  lymphoma. 

Carcinoma. — A  cancer  may  be  defined  to  be  a  tumor,  composed  of  embryonic 
cell  elements  of  varying  shape  and  proportions,  collected  in  groups,  which  groups 
or  clusters  are  partially  separated  by  a  well-defined  stroma. 

While  the  elements  of  the  carcinomata  do  not  always  differ  so  widely  from 
those  of  the  sarcomata    (especially  the  more  embryonic  cells  of  this  latter  neo- 


''3^^^^Pi''\ 


% 
M 


^ 


Fig.  733. — Development  of  carcinoma,    s,  Bundles  of  fibrous  tissue  containing  occasional  connective-tis- 
sue corpuscles,     a,  Cancer  cells  in  groups  or  rows  between  the  stroma.      (After  Cornil  and  Ranvier.) 

plasm),  the  alveolar  structure  of  the  stroma  of  cancer  will  always  render  it  easy 
of  recognition. 

Cancer  cells  vary  greatly  in  shape  and  size,  being  round,  flat,  ovoid,  fusiform, 
polygonal,  and  measuring  from  ^-^Vo  ^o  tjot  ^^^l  -^  inch  in  diameter.  Each 
cell  may  contain  one  or  many  nuclei.  The  nucleus  is  often  of  large  size,  at 
times  occupying  the  greater  portion  of  the  cell  sj^ace.  The  nucleoli  are  especially 
prominent.  Tlie  cell  elements  of  carcinoma  are  contained  within  the  alveoli,  and 
float  in  or  are  in  contact  with  a  Juice  of  varying  quantity  and  consistence. 

The  walls  of  the  alveoli  are  composed  of  a  fibrillated  structure  of  modified 
connective  tissue.     In  old  tumors  the  fibers  of  the  stroma  are  closely  packed  to- 

wens.  (2)  Sebaceous  adenomas  arise  from  glands  which  are  lobulated  like  those  about  the  nose 
and  ear.  (Park.)  (3)  Adenocarcinoma,  a  rare  tumor  existing  in  the  glands  of  Tyson,  (a) 
Pituitary  adenomas.  (6)  Those  of  the  prostate,  (c)  Salivary  glands;  also  in  the  mucous  membrane 
of  the  stomach,  the  rectum,  Fallopian  tubes,  etc. 

Epithelioma  occurs  especially  in  the  meso-cutaneous  borders.  A  rapidly  destructive  type 
of  this  neoplasm  was  formerly  known  as  rodent  ulcer. 

Carcinoma,  a  tumor  springing  from  preexisting  gland  tissue.  Scirrhus  and  colloid,  in  the 
breast;  considered  as  acinous  and  duct  cancers.  The  former  of  the  scirrhus  type,  may  arise  in 
any  part  of  the  breast,  and  when  located  near  the  nipple  causes  retraction.  Lymphatic  infection 
occurs  early  in  this  form.  Duct  carcinoma  appears  about  the  time  of  the  menopause,  and  is 
most  common  in  the  terminal  branches. 

Malignant  chorioji  epithelioma  follow  pregnancy  generally  within  a  few  months  and  are  often 
preceded  or  accompanied  by  a  hydatidiform  mole. 

Suprarenal  epithelioma,  a  tumor  of  the  kidney  springing  from  remnants  of  suprarenal  tissue. 
Very  rare.     (Grawitz.) 


NEOPLASMS  701 

gether,  -ff-hile  in  more  recent  neoplasms  connective-tissue  corpuscles  are  frequently 
observed  between  the  clusters  of  cells  (Fig.  733).  The  alveolar  arrangement  of 
the  stroma  is  well  shown  in  Fig.  734,  in  which  the  cancer  cells  have  been  removed. 

The  alveoli  are  not  isolated  cavities,  but  communicate  more  or  less  freely.  In 
the  connective-tissue  walls  of  the  alveoli  the  blood  vessels  and  lymph  channels  are 
lodged.  In  the  development  of  a  carcinoma  the  proliferation  among  the  cells 
proper  of  the  neoplasm  excites  a  similar  condition  in  the  connective-tissue  cells  of 
the  neighboring  and  involved  tissues,  and,  coincident  with  the  multiplication  of  the 
cancer  elements,  the  connective-tissue  elements  are  developed.  In  this  way  the 
stroma  is  formed  aroimd  and  among  the  cancer  cells,  and  in  rare  instances  this 
proliferation  is  so  rapid  that  clusters  of  adipose  cells  are  caught  within  the  neoplasm 
and  remain  as  such  in  the  process  of  growth  in  the  tumor. 

Carcinomata  spread  by  direct  invasion  of  contiguous  tissues,  and  along  the 
route  of  the  IjTaph  channels. 

It  is  not  uncommon  (as  established  by  Cornil  and  Eanvier)  for  induration  and 
hypertrophy  of  the  ganglia  of  the  nearest  hauph  plexus  to  occur  before  metastasis 
has  taken  place,  a  fact  of  great  interest  to  the  surgeon.  This  early  glandular 
hyperplasia  is  due  to  the  irritation  caused  by  the  neoplasm,  and  though  less  acute 
is  not  unlike  the  adenitis  of  an  ordinary  inflammatory  process. 

Four  chief  varieties  of  cancer  are  recognized — the  scirrhus,  encephaloid,  mucoid 
or  colloid,  and  epithelioma. 

Scirrhus,  or  hard  cancer,  is  distinguished  by  the  greater  proportion  and  thick- 
ness of  the  stroma,  in  comparison  with  the  cell  elements.  Many  of  the  cells  in 
this  variety  of  neoplasm,  especially  those  more  deeply  situated,  undergo  extensive 
granular  metamorphosis,  and  appear  as  granular  corpuscles,  having  lost  all  the 
characteristics  of  the  cancer  elements. 

Encephaloid,  soft,  or  medullary  cancer  is  rich  in  cells  and  cancer-Juice,  while 
the  stroma  is  very  thin.  It  is  more  vascular,  and  in  gross  appearance  is  like 
broken-up  brain  matter;  hence  the  name  encephaloid.  Owing  to  the  embryonic 
cliaracter  of  the  new-formed  blood  vessels  and  the  lack  of  resistance  from  the 
scantily  developed  stroma,  aneurismal  dilatations  of  the  vessels  are  common,  and 
rupture  frequently  occurs. 

Colloid  cancer  is  characterized  hj  the  presence  within  the  alveoli  of  a  fluid  rich 
in  mucin,  which  substance  also  appears  in  all  the  foci  that  may  be  developed  by 
metastasis.  Many  of  the  cells  disappear,  and  those  which  remain  are  unusually 
large  and  swollen.  The  alveoli  are  also  distended  and  the  walls  more  translucent 
than  in  scirrhus. 

The  changes  which  cancers  undergo  are  chiefly  granular  metamorphosis  and 
ulceration.  The  cells  of  the  deeper  portions  of  the  neoplasm,  deprived  of  sufficient 
nourishment  by  reason  of  their  central  jjosition,  break  down  in  a  granular  detritus, 
which  is  absorbed  and  carried  away  in  part  by  the  blood  vessels,  but  chiefly  by 
the  lymph  channels.  In  older  tumors  this  gradual  loss  of  cellular  elements  is 
followed  by  contraction  of  the  stroma  and  sinking  in  or  retraction  of  the  integu- 
ment. Inflammation  and  ulceration  of  a  cancer  may  result  from  direct  irritation 
from  without,  or  may  occur  as  a  residt  of  the  growth  of  the  neoplasm,  which  thus 
often  cuts  ofE  its  own  nutrition.  The  process  is  not  unlike  ulceration  in  the  normal 
tissues,  only  the  granulations  are  often  very  exuberant  and  the  death  of  tissue 
rapid.  All  forms  of  carcinoma  are  subject  to  the  deposit  of  pigment,  and  under 
such  conditions  have  been  termed  melanotic  cancer. 

Causes.- — Cancer  is  a  disease  of  adult  and  of  late  adult  life.  Scirrhus,  enceph- 
aloid, or  colloid  cancer,  under  twenty  years  of  age,  is  exceedingly  rare.  It  occurs 
chieflv  in  the  period  of  life  between  thirty  and  sixty.  Women  are  more  frequently 
attacked  than  men.  Prolonged  irritation  is  undoubtedly  the  chief  exciting  cause 
of  the  development  of  this  neoplasm.  In  evidence  of  this  conclusion  is  the  fact 
that  those  portions  of  the  body  which  are  subjected  to  the  greatest  amount  of  irri- 
tation are  most  often  affected.  The  mammary  gland,  pylorus,  rectum,  and  uterus 
are  the  more  common  locations  of  cancer. 

Diagnosis. — The  recognition  of  cancer  is  positive  only  by  microscopical  exam- 
ination, and  depends  in  part  upon  the  peculiar  characters  of  the  cells   already 


702 


NEOPLASMS 


noted,  but  chiefly  upon  the  ajspearance  of  the  stroma.  Clinically,  the  diagnosis 
will  d'epend  upon  the  age  of  the  patient,  the  location  of  the  tumor,  its  consistence, 
immobility,  and  the  condition  of  the  lymphatic  glands  in  the  line  of  the  vessels 
toward  the  center.  A  tumor  occurring  after  the  age  of  thirty-five,  of  a  mildly 
painful  character,  and  increased  when  firm  pressure  is  exercised ;  steadily,  although 
at  times  slowly,  enlarging,  movable,  it  may  be,  beneath  the  skin  or  within  the 
substance  of  the  organ  or  part  in  which  it  is  located,  yet  not  freely  so,  should  be 
looked  upon  with  suspicion.  If  it  has  existed  for  several  months,  and  there  is 
retraction  of  the  integument  over  a  portion  of  the  mass,  together  with  induration 
of  the  nearest  lymphatic  glands,  the  diagnosis  of  cancer  is  almost  positive.  As 
between  the  three  different  forms  of  cancer,  it  may  be  said  that  scirrhus  is  much 
the  more  common,  is  slower  in  growth,  and  harder  to  the  touch.  Colloid  cancer 
or  the  colloid  degeneration  of  scirrhus  is  also  hard,  and  grows  slowly,  and  from 
palpation  and  inspection  cannot  be  differentiated  from  scirrhus  with  any  certainty. 
It  is  comparatively  rare.  Encephaloid  is  a  soft,  elastic  tumor,  not  always  of 
uniform  consistence,  but  generally  of  smooth  surface,  and  always  of  rapid  growth. 
Its  vascularity  is  therefore  much  luore  noticeable  than  that  of  either  of  the  other 
varieties,  and  metastasis  is  more  rapid.  As  between  sarcoma,  the  chief  diagnostic 
points  are  the  age  of  the  patient,  sarcoma  being  more  common  in  the  young, 
cancer  in  the  old  and  middle-aged;  the  lymphatics  are  not  involved  in  sarcoma, 
except  when  extensive  ulceration  and  septic  absorption  occurs;  in  general,  the 
superficial  veins  of  sarcoma  are  more  dilated  and  perceptible,  and  the  tumor  more 
elastic. 


Fig.  734. — Stroma  of  cancer  from  which  the  cell 
elements  have  been  removed.  (After  Cornil 
and  Ranvier.) 


Fig.  735. — Lobular  or  spherical  epithelioma,  250 
diameters.     (After  Cornil  and  Ranvier.) 


The  excision  of  a  j)ortion  of  a  tumor  for  immediate  microscoi^ical  examina- 
tion for  purposes  of  diagnosis  is  indicated  in  all  doubtful  cases.  Under  proper 
conditions  a  few  minutes  should  suffice  to  determine  the  proper  operative  pro- 
cedure. 

Epithelioma. — An  epithelioma  may  be  defined  as  a  neoplasm,  the  embryonic 
elements  of  which  assume,  in  a  varying  degree,  the  shape  and  arrangement  of  the 
normal  epithelium.  Developing  usually  in  the  skin  or  mucous  membranes,  they 
at  times  originate  in  tissues  remote  from  them,  as  in  the  bones. 

Malignant  epitheliomata  may  be  divided  into  two  classes:  1,  the  flat  or  super- 
ficial ;  2,  the  tubular  or  deep. 

The  first  variety  is  by  far  the  more  common.  It  occiirs  by  preference  upon  the 
muco-cutaneous  surfaces,  as  the  lips,  prepuce,  anus,  vulva,  etc.,  but  may  appear 
either  upon  the  skin  or  mucous  surfaces,  remote  from  any  line  of  union  of  these 
coverings,  as  the  tongue,  cheek,  face,  etc. 


NEOPLASMS 


703 


Flat  epithelioma  usually  begins  as  a  nodule  or  induration  of  small  size,  slightly 
reddened  at  its  margin,  the  center  of  which  very  early  in  its  history  breaks  down 
into  a  dirty  idcer  which,  when  kept  fairly  clean,  is  reddish  in  color,  and,  when 
not  cleansed,  is  covered  with  a  grayish  mass  of  pus  and  broken-down  tissue,  either 
solidified  into  a  crust  or  scab,  or  in  a  softened  state.  The  margins  of  the  ulcer 
are  sinuous,  hard,  and  everted.  It  may  limit  itself  to  a  small  area,  or  develop 
steadily,  and  sometimes  with  great  rapidity  until,  after  extensive  destruction  of  the 
tissues  in  its  neighborhood,  death  ensues  from  hsemorrhage,  sepsis,  or  metastasis. 
Pain,  usually  mild  in  character,  is  always  a  symptom  of  this  disease.  Lymphatic 
engorgement  may  occur  in  the  first  few  weeks,  but  usually  from  four  to  eight 
months,  and  even  a  longer  time,  may  elapse. 

Examined  microscopically,  this  form  of  epithelioma  is  seen  to  be  composed  of 
flattened  cells,  containing  one  or  several  nuclei,  with  a  tendency  on  the  part  of 
the  elements  to  form  themselves  in  concentric  layers  (Fig.  735).  In  the  center 
of  these  spheres  of  flattened  epithelia  are  frequently  seen  a  few  cells  which  have 
undergone  the  colloid  change.  Farther  out  the  surrounding  cell  elements  are  more 
embryonic  in  character,  cylindrical,  spherical,  or  polygonal  from  lateral  compres- 
sion, the  mass  being  limited  externally  Ijy  a  stroma  of  connective  tissue,  varying 
in  quantity,  which  separates  one  epithelial  nest  from  the  others  composing  the 

entire  neoplasm.  In  the  process  of 
ulceration  an  epithelioma  is  sur- 
rounded by  a  zone  of  embryonic  tis- 
sues due  to  the  cell  proliferation  of 
fl — ili^^^'^M^SJ^^S  ^^^  inflammatory  process. 


Fig.  736. — Tubular  epithelioma,  a.  Tubules  or 
cylinders  cut  obliquely,  b.  Connective-tissue 
stroma.     (After  Comil  and  Ranvier.) 


Fig.  737. — Tubular  epithelioma  with  cylindrical 
elements,  a,  Tubule  cut  across,  b,  Tubule 
cut  in  its  long  axis,  c,  Cylindrical  epithelia. 
(.'^iter  Cornil  and  Ranvier.) 


Tubular  epitheliomata  are  considered  somewhat  less  malignant  than  the  lobular 
or  bird's-nest  variety  just  described.  After  reaching  a  certain  stage  in  their  develop- 
ment, they  may  remain  stationary;  but,  in  the  majority  of  instances,  the  tendency 
is  to  grow,  as  well  as  to  recur  after  removal.  They  are  usually  situated  upon  the 
skin,  where  they  originate  in  the  sweat  or  sebaceous  glands  or  upon  the  mucous 
memliranes,  where  they  spring  from  the  follicles  of  these  surfaces.  The  antrum 
maxillare  is  occasionally  the  seat  of  this  variety  of  neoplasm. 

Microscopically,  the  fiat-celled  epitheliomata  are  composed  of  pavement  or 
tessellated  cells,  crowded  in  tubules  or  cyliaders,  which  are  long,  more  or  less 
irregular  in  shape,  at  times  anastomosing  with  each  other,  and  are  held  together 
by  a  stroma  of  connective  tissue   (Fig.  736). 

The  general  shape  of  these  neoplasms  is  oval  or  round. 

Treatment.— The  proper  treatment  of  epithelioma  will  vary  with  the  special 
character  of  the  neoplasm  and  its  location.  The  simpler  forms  of  flat  epithelioma 
developing  away  from  a  mucous  surface — i.  e.,  not  communicating  with  a  muco- 
cutaneous surface — yield  readily  to  the  application  of  arsenious-acid  paste.    Even 


704  NEOPLASMS 

when  situated  near  the  eye  and  practically  communicating  with  the  mucous  mem- 
brane of  the  eyelid,  it  may  still  yield  to  this  remedy  without  danger  to  the  integrity 
of  the  eye.  On  the  other  hand,  when  an  ei^ithclioma  is  situated  upon  the  lip,  it 
should  be  removed  by  free  excision  at  the  very  earliest  possible  moment.  Epitheli- 
oma of  the  tongue  is  one  of  the  most  malignant  of  all  forms  of  neoplasm  and  is 
amenable  to  n©  other  treatment  than  early  and  wide  extirpation  of  the  part 
involved.  After  lymphatic  engorgement  and  metastases,  the  application  of  Mars- 
den's  paste  to  the  epitheliomatous  ulcer  is  of  doubtful  propriety  unless  a  thorough 
dissection  of  all  the  involved  glands  has  been  inade  prior  to  the  application  or  at 
the  same  time.  When,  after  metastatic  invasion  one  or  more  of  the  lymphatic 
glands  have  been  removed,  it  is  advisable  to  apply  arsenious-acid  paste  in  the 
wound  so  made.  The  action  of  arsenious  acid  is  to  destroy  the  weak  tissue  of  the 
epitheliomatous  growth.'  In  applying  it,  it  is  always  essential  that  it  rest  in  con- 
tact with  a  raw  surface.  If  an  epithelioma  is  covered  with  a  thick  crust,  this 
shoidd  be  removed  either  by  the  knife  or  by  the  application  of  caustic  potash.  The 
stick  of  caustic  potash,  when  rubbed  over  these  crusts,  rapidly  destroys  them,  and 
enables  the  surgeon  to  expose  the  underlying  diseased  surface  in  five  or  ten  min- 
utes. The  formula  employed  is  the  following:  Arsenious  acid,  two  drams;  pow- 
dered gum  acacia,  one  dram;  cocaine,  eighteen  grains.  Mix  and  rub  well  together 
in  a  mortar.  When  ready  for  use,  a  sufficient  quantity  should  be  moistened  into 
a  paste  about  as  thick  as  half-melted  butter  by  adding  water  drop  by  drop.  The 
paste  should  be  laid  about  an  eighth  of  an  inch  thick  upon  a  piece  of  lint  or  gauze, 
and  should  extend  about  one  eighth  of  an  inch  beyond  the  margin  of  the  ulcer 
upon  which  it  is  applied.  It  is  well  not  to  cover  more  than  a  square  inch  of 
surface  at  a  time,  for  fear  of  absorption  of  too  much  arsenious  acid.  The  length 
of  time  the  paste  is  to  remain  on  will  depend  upon  the  result  in  a  given  case.  I 
usually  apply  it  about  nine  o'clock  in  the  morning  and  leave  it  on  until  nine  at 
night,  when  it  is  removed,  and  a  simple  dressing  of  vaseline  applied.  The  next 
morning  the  paste  is  applied  again  and  left  on  for  about  six  hours.  An  applica- 
tion of  eighteen  hours  with  an  interval  of  about  twelve  hours  will  suffice  for 
ordinary  cases.  Upon  the  ala?  nasi  or  eyelids  four  or  five  hours  will  be  safer. 
The  after-treatment  is  a  simple  vaseline  dressing.  In  the  very  mildest  form  of 
epithelioma,  such  as  is  caused  by  friction  of  the  spectacles  upon  the  nose  or 
that  appearing  in  the  form  of  little  pimples  upon  the  face,  which  have  been  con- 
verted into  epithelioma  by  irritation,  Marsden's  old  formula — equal  parts  of  ar- 
senious acid  and  gum  acacia — will  suffice. 

Small  scaly  formations  quite  frequently  observed  on  the  face  in  elderly  sub- 
jects will  at.  times  disappear  if  the  area  involved  is  thoroughly  lubricated  with 
vaseline  cold-cream  night  and  morning. 
'  In  the  deep  or  tubular  form  the  skin  is  usually  not  broken,  the  epitheliomatous 
elements  having  developed  in  the  follicles  and  practically  beneath  the  skin.  The 
paste  will  not  act  directly  upon  the  unbroken  skin,  and  therefore  in  these  cases 
it  is  often  necessary  to  remove  the  overlying  skin,  by  dissection,  usually  under 
cocaine  ansesthesia,  applying  gauze  to  arrest  haemorrhage,  and  then  applying  the 
paste  after  all  bleeding  has  stopped.  It  is  sometimes  necessary  after  applying  the 
paste  to  use  the  curette  to  scrape  away  the  destroyed  tissue.  If  the  ulcer  does  not 
heal  readily  within  two  or  three  weeks  after  such  application — i.  e.,  if  in  one  or  two 
spots  upon  the  margin  there  is  any  induration,  the  application  may  be  repeated  on 
these  places.  The  practitioner  may  rest  assured  that  by  following  the  above  method 
in  properly  selected  cases  the  vast  majority  will  be  cured  by  one  application. 

It  has  been  observed  in  a  number  of  instances  that  these  milder  forms  of  flat 
epithelioma  have  undergone  certain  modifications  during  an  attack  of  erysipelas 
which  was  either  located  at  the  ulcer  or  in  another  portion  of  the  body.  One  such 
experience  occurred  in  my  own  practice;  an  epitheliomatous  ulcer  on  the  temple 
became  infected  with  erysipelas,  which  ran  its  usual  course,  during  which  time  the 
ulcer  disappeared  and  remained  absent  for  several  months.  It  recurred,  however, 
and  was  cured  by  the  arsenious-acid  paste. 

Lymphadenoma. — This  variety  of  neoplasm  is  entitled  to  be  classed  with  the 
malignant  tumors.     It  consists  of  new-formed  lymphatic  gland  tissue,  and  may 


NEOPLASMS 


705 


occur  in  preexisting  glands  or  in  any  of  tlie  tissues  of  the  body.  The  liver,  spleen, 
and  kidneys,  the  testicle,  the  alimentary  canal,  the  bones  and  integument,  may 
all  be  the  seat  of  these  new  formations.  Coincident  with  the  development  of  these 
neoplasms,  the  proportion  of  white  blood-corpuscles  in  the  volume  of  blood  is  enor- 
mously increased,  until  death  ensues  from  leucocythgemia.  These  tumors  may  be 
of  any  size,  from  a  millet  seed  up  to  several  inches  in  diameter,  are  soft  to  the 
touch,  and  usually  not  well  defined.  They  cannot  be  diagnosticated  from  other 
gland  tissues  unless  examined  microscopically,  when  they  are  seen  to  consist  of  a 
connective-tissue  framework  or  reticulum,  along  the  fibrills  of  which  run  the 
capillaries,  and  in  the  meshes  of  the  reticulum  the  lymph  corpuscles  are  situated 
(Fig.  738). 

The  prognosis  is  grave,  and  the  condition  does  not  justify  surgical  inter- 
ference. 

Sarcomata. — A  sarcoma  is  a  tumor  the  elements  of  which  have  their  type  in 
the  normal  connective  tissues.  The  cells  of  a  sarcoma  may  be  purely  embryonic, 
or  may,  in  a  certain  sense,  resemble  the  more  developed  elements.  They  are,  how- 
ever, not  capable  of  organization  into  a  permanent  tissue. 

Classified  according  to  the  shape  and  size  of  the  cell  elements  which  prepon- 
derate in  their  composition,  they  are  called — 1,  round;  2,  spindle;  3,  giant-cell 
sarcoma. 

The  cell  elements  of  the  sarcomata  not  only  vary  in  size  and  shape,  but  in  the 
number  of  their  nuclei,  of  which  there  may  be  from  one  to  thirty  or  more.     In  the 


Fig.  738. — Reticul?.r  structure  of  a  lymphatic  in- 
testinal follicle,  a  6,  Capillary  vessels  with 
nuclei  in  their  walls,  c,  Meshes  of  the  reticu- 
lar structure  containing  lymphatic  corpuscles. 
(After  Frej'.) 


Fig.  739. — Injection  of  the  vascular  network  of 
an  osteo-sarcoma.      (.\fter  Billroth.) 


more  fully  developed  or  spindle-celled 
neoplasm  the  elements  are  arranged  in 
bundles  which  run  in  all  directions.  These  tumors  possess  little  or  no  intercellular 
substance,  the  elements  resting  in  contact  or  separated  by  the  blood  vessels  which 
freely  permeate  them.  The  richness  of  the  blood  supply  and  the  proportion  of 
the  tumor  occupied  by  these  channels  are  well  shown  in  Fig.  739. 

The  size  and  number  of  the  blood  channels  depend  upon  the  structure  of  the 
tumor,  the  round-cell  sarcoma  being  most  vascular,  while  the  vessels  are  less 
numerous  and  of  smaller  caliber  in  the  spindle-cell  variety. 

The  intercellular  substance  also  varies  in  quantity,  being  scarcely  perceptible 
in  the  round-cell  tumor,  and  more  distinct  in  the  spindle  or  fusiform  variety.  In 
some  of  the  sarcomata  normal  connective-tissue  fibers  may  exist,  and  these  are 
believed  to  have  been  caught  in  the  development  of  the  neoplasm. 

The  sarcomata  in  general  develop  with  great  rapidity,  and  tend  to  invade  or 
infiltrate  the  structures  in  their  immediate  neighborhood.  In  this  the  different 
forms  of  tumor  also  differ.  The  round-celled  neoplasm  grows  more  rapidly  than 
the  others,  and  is  more  apt  to  invade  the  surrounding  tissues  than  the  fusiform- 
cell  variety.  It  is  not  the  rule  for  these  neoplasms  to  become  encapsuled,  although 
this  may  occur  in  the  spindle-  or  giant-cell  variety. 


706 


NEOPLASMS 


The  three  varieties  of  cells  may  exist  in  the  same  tumor.  According  to  Cornil 
and  Eanvier,  a  careful  search  will  reveal  the  presence  of  giant  cells  in  varying 
numbers  in  almost  all  sarcomata. 

The  retrogressive  changes  which  these  tumors  undergo  are  fatty  and  calcareous 
deo'eneration.  The  deejjer  cells  of  tumors  of  considerable  size — in  otlier  words^ 
those  farthest  removed  from  tlie  supply  of  nutrition — very  commonly  undergo  the 
fatty  or  granular  metamorphosis.  A^ot  infrequently  this  granular  metamorphosis 
proceeds  so  rapidly  that  the  blood  vessels  of  the  tumor  become  occluded  with  the 
fatty  detritus  (granular  infarction).  In  this  way  the  nutrition  in  certain  portions 
of  the  growth  is  interfered  with,  increasing  the  area  of  fatty  metamorphosis,  or 
inducing  gangrene  from  a  sudden  arrest  of  the  blood  current. 

Calcareous  degeneration  occurs  in  certain  of  the  sarcomata  irrespective  of  their 
being  situated  in  the  neighborhood  of  bone.  Pigmentation  occasionally  occurs, 
and  this  form  is  at  times  separately  classified  as  melanotic  sarcoma.  It  is  apt 
to  take  place  in  the  small,  round-cell  tumors.  Acute  inflammation  in  a  sarcoma 
is  almost  always  followed  by  the  proliferation  of  an  exuberant  granulation  tissue, 
with  more  or  less  extensive  gangrene  and  death  of  the  mass.  Excessive  and  at 
times  fatal  hemorrhage  may  occur  in  the  process  of  sloughing. 

A  common  accident  in  the  evolution  of  a  sarcoma  is  the  extravasation  of  blood 
from  rupture  of  the  walls  of  the  new-formed  vessels.  Such  is  the  crude  condition 
of  these  tumors  that  even  the  cells  which  compose  the  vessels  are  embryonic,  and 
readil}'  give  way,  allowing  the  escape  of  blood  among  the  cell  elements  and  inter- 
cellular spaces.  The  more  nearly  the  development  of  the  cells  approaches  a-  normal 
tissue,  the  less  probability  there  is  of  extravasation.  The  blood  thus  escaped  may 
be  absorbed  or  become  encapsuled  by  pressure  upon  the  cells  near  the  point  of 
rupture  and  become  converted  into  a  blood  cyst. 

Mucoid  degeneration  is  also  occasionally  met  with  in  these  neoplasms.  The 
cells  of  certain  portions  of  the  tumor  disappear,  leaving  cysts  or  alveoli  varying 
in  size  from  the  smallest  up  to  as  large  as  two  or  three  inches  in  diameter  in  large 


Fig.  740. — Alveolar  sarcoma. 
(After  Green.) 


Fig.  741. — Round-cell  sarcoma. 
(After  Green.) 


tumors.  The  cysts  are  occupied  by  an  amber-colored  or  reddish-brown  fluid,  which, 
examined  with  the  microscope,  demonstrates  the  presence  of  blood-corpuscles  in 
various  conditions  of  degeneration.  Chemically,  the  fluid  yields  mucin.  The  name 
alveolar  sarcoma   (Fig.  740)  has  been  given  to  this  form  of  tumor. 

Special  Forms  of  Sarcoma — Eound-ceU  Variety. — The  cells  are  analogous  to 
the  embryonic  elements  of  the  ordinary  inflammatory  process,  from  which  they 
cannot  be  distinguished.  They  possess  one  or  more  nuclei  and  nucleoli,  and  are 
spherical,  or  with  slightly  irregular  outlines  from  reciprocal  pressure.  The  inter- 
cellular substance  is  homogeneous,  and  either  very  scanty  or  entirely  absent  (Fig. 
741).  The  vessels  and  blood  channels  have  been  described.  This  variety  of  sar- 
coma occurs  everywhere.  In  the  neuroglia  of  the  brain  and  the  neurilemma  it  is 
called  neurosarcoma  or  glioma. 

Spindle-cell  Sarcoma. — The  cells  of  this  variety  are  elongated  or  fusiform  in 
shape,  containing  usually  one.  at  times  several,  nuclei.  The  ends  of  the  spindle 
may  be  single  or  bifurcated  (Fig.  743).  The  cells  vary  in  size  from  ^-jVo-  to  f^^ 
of  an  inch  in  diameter,  and  are  arranged  in  bundles  running  in  various  directions 
(Fig.  743). 


NEOPLASMS 


707 


Clinically,  this  is  the  most  comBion  form  of  sarcoma.  They  are  slower  in  de- 
velopment, firmer  to  the  feel,  and  less  vascular,  and  of  smaller  dimensions  than  the 
preceding  variety.  As  stated,  they  are  somewhat  less  malignant.  They  may,  in 
rare  instances,  be  encapsuled,  although  the  rule  is  to  invade  the  surrounding  tissues. 


Fig.  742. — Multipolar  cells  of  a 


(After  Cornil  and  Ranvier.) 


The  favorite  location  for  their  development  is  the  periosteum  and  in  the  substance 
of  the  bones. 

They  attack   the   glandular   structures,   not  infrequently   affecting  the  breast. 
While  developing  here,  the  increased  vascularity  of  the  neoplasms  induces  hyper- 


FiG.  743. — Spindle-cell  sarcoma. 


00  -s, 

(After  Virchow.) 


aemia  of  the  glandular  apparatus  of  the  breast  witli  consequent  proliferation  of 
the  epithelia,  a  condition  which  has  been  termed  by  Billroth  adeno-sarcoma. 

Giant-cell  Sarcoma. — The  cells  of  this  neoplasm  are  of  all  sizes  and  shapes: 
spherical,  fusiform,  and  irregularly  oval,  having  at  times  one,  at  others  thirty  or 
more  nuclei  (Fig.  744).  They  closely  resemble  the  cells  of  the  normal  marrow 
of  fcetal  bones.  Clinically,  this  form  of  sarcoma  is  met  with  usually  in  the  bones, 
especially  in  the  lower  jaw  and  the  long  bones.  It  may  develop  to  an  enor- 
mous size,  remaining  practically  confined  to  a  single  bone;  less  frequently  spread- 
ing to  the  surrounding  soft  parts.  Bones  so  affected  at  times  become  friable, 
being  readily  fractured  from  the  body-weight,  or  yield  a  crackling  sound  upon 
palpation. 

Clinical  Features. — Sarcomata  may  be  met  with  in  all  conditions  and  at  any 
period  of  life.     Comparatively  speaking,  they  are  rare  in  old  age,  occurring  chiefly 


708 


NEOPLASMS 


in  children,  and  adults  under  thirty.  Occasionally  they  are  congenital.  Both  sexes 
are  equally  liable  to  be  attacked.  They  are,  as  a  rule,  idiopathic  in  origin,  in  rare 
cases  being  due  to,  or  at  least  following,  an  injury  to  the  part  involved  in  the 


Fig.  744. — Giant-cell  sarcoma.     From  a  sarcoma  of  bone.     (After  Ordonez.) 

neoplasm.  Sarcomata  are  among  the  most  malignant  new  formations,  not  only 
recurring  in  loco  after  removal,  but  tending  to  be  disseminated  by  the  blood  vessels. 
Unlike  the  earcinomata,  they  have  no  lymph  channels,  and  metastasis  must  occur 
by  the  Jjlood  vessels  which  enjoy  free  anastomoses  with  the  caverns  and  sinuses 

of  the  neoplasm. 

The  degree  of  malignancy  of  a  sarcoma 
is,  in  general,  in  proportion  to  the  embryonic 
character  of  the  elements  of  which  it  is  com- 
posed. Thus,  the  round-celled  tumors  of 
rapid  development  are  most  malignant,  the 
spindle-celled  next,  the  giant-celled  last  in 
this  order. 

As  to  location,  no  tissue  is  exempt.  They 
are  frequently  met  with  in  the  skin  and  sub- 
cutaneous tissues  (Fig.  '7i5) ;  also  the  osseous 
tissues,  especially  the  long  bones,  furnish  a 
favorite  seat  for  them.  Those  developing 
from  within  are  chiefly  the  myeloid  or  giant- 
celled  variety;  those  of  periosteal  origin  are 
round-  or  spindle-celled. 

Sarcoma  of  the  bones  is  exceedingly  ma- 
lignant. 

From  the  foregoing  it  is  evident  that  the 
prognosis  in  any  of  the  varieties  of  sarcoma 
is  unfavorable.  The  gravity  increases  with  the  duration  of  the  tumor,  its  location 
near  the  trunk,  and  with  the  rapidity  of  its  growth. 

The  round-celled,  especially  those  which  have  undergone  the  melanotic,  mucoid, 


Fig.  745. — Sarcoma  of  the  scalp  and  neck. 


NEOPLASMS  709 

or  alveolar  change,  are  most  dangerous;  next,  the  spindle-celled;  and,  lastly,  the 
myeloid  or  giant-celled  variety/ 

Diagnosis. — In  the  differentiation  of  sarcoma  from  scirrhus  and  colloid  can- 
cers, lipoma,  fibroma,  cysits,  and  other  non-malignant  tumors,  the  following  points 
are  essential : 

Cancer  is  a  disease  of  adult  life.  It  is  extremely  rare  under  the  tliirt3'-fifth 
year,  while  the  large  majority  of  sarcomata  under  this  age  and  in  general  are  seen 
in  the  growing  period  of  life,  or  within  the  first  years  after  maturity.  Carcinomata 
as  a  rule  affect  the  glandular  apparatus,  as  the  breast,  stomach,  and  bowels. 
Sarcoma  is  exceedingly  rare  in  these  locations.  Sarcoma  involves  usually  the 
extremities,  and  a  favorite  location  is  in  the  bones  or  periosteum.  When  a  gland 
is  involved,  it  is  by  preference  the  parotid  or  glands  of  the  neck.  Sarcomata  grow 
very  much  more  rapidly  than  other  neoplasms,  are  immovable,  the  skin  covering 
is  more  or  less  tense,  and  usually  a  rich  network  of  veins  is  observed.  From  a 
cyst,  a  diagnosis  is  made  easily  by  aspiration.  From  fibroma  of  the  skin  in  the 
young  the  diagnosis  is  difficult,  and  usually  requires  a  section  under  microscopical 
examination  for  confirmation.  These  examinations  should  never  be  made  until 
the  patient  is  under  the  anesthetic  and  prepared  for  a  radical  operation.  Lipoma 
is  soft  and  movable,  usually  develops  superficially,  and  should  not  be  mistaken 
for  sarcoma. 

Treatment. — Early  and  wide  extirpation  is  the  immediate  indication,  to  be 
followed  by  a  carefully  managed  streptococcus  infection.  Sarcoma  in  the  bone 
of  an  extremity  demands  amputation  well  away  from  the  tumor,  usually  through 
an  articulation.  Located  in  the  lower  end  of  the  tibia,  the  knee-joint  should  he 
selected ;  in  the  condyles  of  the  femur  at  or  near  the  hip-joint,  preferably  disar- 
ticulation. If  the  tarsus  or  metatarsus  is  involved,  and  the  neoplasm  has  not  been 
recognized  in  its  incipiencj',  amputation  above  the  ankle  is  indicated.  In  the 
phalanges  of  the  hand  or  foot,  amputation  of  the  membrane  involved  may  suffice. 
When  located  at  the  lower  end  of  the  radius  or  ulna,  disarticulation  at  the  elbow 
is  the  safer  course,  while  disarticulation  at  the  shoulder  is  usually  indicated  when 
any  portion  of  the  humerus  is  involved.  If  the  tumor  has  developed  from  the 
periosteum  by  a  limited  pedicle,  and  is  so  situated  that  the  bony  attachment 
can  be  deeply  removed  by  the  chisel  without  involving  the  supporting  power  of 
the  bone,  this  conservative  procedure  may  be  considered,  but  if  in  doubt  the 
operator  should  lean  to  the  side  of  ultimate  safety  in  dealing  with  this  malignant 
disease. 

A  careful  analysis  of  eighty-three  cases  by  the  author  which  required  amputa- 
tion at  the  hip-joint  by  his  method  on  account  of  sarcoma,  showed  that  recurrence, 
not  in  the  stump  but  in  the  viscera,  was  the  rule  within  the  first  two  years  after 
the  operation.^ 

It  is  evident  that  the  germs  of  the  neoplasm  had  already  been  deposited  in  the 
lungs  before  the  amputation,  and  were  only  awaiting  conditions  which  favored 
their  proliferation. 

Should  the  tumor  involve  only  the  soft  structures,  it  should  be  removed  by  as 
wide  a  dissection  as  possible,  unless  certain  organs  are  involved  the  removal  of 
which  would  produce  a  too  serious  mutilation.  Under  such  conditions,  and  in 
fact  in  all  inoperable  sarcomas,  the  infection  should  be  thoroughly  tried. 

It  has  long  been  known  that  under  certain  conditions  sarcoma  may  be  cured 
as  the  result  of  erysipelatous  infection.     In  the  experience  of  the  author  it  has 

I  For  a  consideration  of  the  various  mixed  varieties  of  sarcoma,  viz.,  osteoid,  neuro-  and 
lipo-sarcomata,  angeiolithic  sarcoma,  etc.,  the  student  is  referred  to  the  text-books  on  pathology, 
and  especially  to  the  excellent  work  of  Cornil  and  Ranvier,  which  the  author  has  drawn  from 
extensively. 

^One  case,  a  boy  of  14,  was  alive  and  well  9  years  after  operation,  3  survived  7  years  and 
were  still  living,  2  five  years,  3  four  years,  3  three  years,  3  two  and  a  half  years,  9  were  surviv- 
ing two  years  after  operation,  and  3  one  year  and  over.  The  remaining  five  were  well  within 
twelve  months  of  the  operation.  Of  the  fatal  occurrences,  the  location  of  the  metastasis  was  as 
follows:  Lung.  23:  lung  and  brain,  1;  lung  and  pleura,  1;  lung  and  abdomen,  1 ;  pleura,  2; 
abdominal  viscera,  3:  liver,  1;  abdomen  and  chest,  1;  stump,  10;  stump  and  mesenteric  glands, 
1 ;  stump  and  general  metastasis,  1 ;  stump  and  iliac  fossa,  1 ;  lymphatic,  just  above  Ponpart's 
ligament,  1;  sacro-iliac  synchondrosis,  1;  location  not  given,  4;  apoplexy,  1.     Total,  53. 


710  NEOPLASMS 

been  demonstrated  that  the  streptococcus  pyogenes  also  has  an  inhibitory  action 
upon  sarcoma,  and  will,  under  favorable  conditions,  effect  a  permanent  cure. 

While  the  larger  proportion  of  sarcomata  have  not  yielded  to  these  infections, 
in  view  of  the  fact  that  without  this  treatment  recurrence  with  a  fatal  issue  is 
almost  without  exception  the  result,  it  should  be  advised  in  all  instances.  During 
the  author's  connection  with  Mt.  Sinai  Hospital,  in  the  service  of  a  colleague,  Dr. 
A.  G.  Gerster,  a  young  girl  was  admitted  suffering  from  a  sarcoma  of  the  leg,  for 
which  amputation  was  done.  The  disease  recurred  and  amputation  at  the  middle 
of  the  thigh  was  performed;  again  there  was  a  recurrence,  and,  finally,  at  the 
hip-joint  clisarticulation  was  done,  but  the  disease  recurred  in  the  stump.  The 
patient  was  abandoned,  but  fortunately  contracted  erysipelas  in  the  wound.  The 
recovery  from  the  erysipelas  was  followed  by  complete  and  permanent  disappear- 
ance of  the  tumor.  Dr.  Gerster  informs  me,  N'ovember  27,  1907,  more  than 
twenty-five  years  after  this  experience,  that  this  patient  is  entirely  well,  and  still 
actively  engaged  in  her  work  as  a  teacher. 

Drs.  B.  F.  Curtis  and  Andrew  J.  McCosh  have  also  reported  cases  in  which 
this  malignant  neoplasm  has  disappeared  after  erysipelatous  infection. 

That  pyogenic  infection  also  exercises  a  curative  influence  over  sarcoma  is  evi- 
dent from  the  following,  which  occurred  in  the  author's  personal  experience.^ 

In  the  author's  technic,  preference  is  given  to  alternating  infection  by  giving 
at  first  a  series  of  injections  of  the  pure  cultures  of  streptococcus  pyogenes,^  fol- 
lowed by  or  alternated  with  pure  cultures  of  Fehleisen's  coccus  (streptococcus 
erysipelatis) . 

In  dealing  with  an  inoperable  sarcoma,  the  needle  should  not  at  first  be  intro- 
duced into  the  tumor  on  account  of  its  vascularity  and  the  danger  of  throwing 
the  toxine  too  rapidly  into  the  circulation.  The  first  injection  is  not  more  than 
one  minim  of  jjure  undiluted  pyogenic  streptococcus  or  the  same  quantity  of  the 
erysipelas  toxine,  diluted  in  five  or  ten  minims  of  salt  solution,  and  this  should 

-  '  On  May  20,  1884,  at  Mt.  Sinai  Hospital,  a  man  about  twenty-eight  years  of  age  was  admitted 
with  the  following  history:  About  one  year  previous  he  had  received  a  blow  upon  the  abdomen 
over  the  right  iliac  region  which  was  followed  by  induration  and  the  development  of  a  neoplasm 
which,  at  the  time  of  examination  was  4x6  inches  in  surface  measurement,  and  Si  inches  in 
thickness.  On  account  of  the  involvement  of  the  abdominal  wall,  it  was  found  impossible  to  re- 
move it.  A  section  extending  entirely  through  the  mass  was  excised  and  examined  by  Dr.  William 
H.  Welch  and  two  other  competent  pathologists.  The  diagnosis  of  each  was  spindle-celled  sarcoma. 
Injections  of  Fowler's  solution  were  advised  and  were  continued  for  one  week.  They 
were  so  painful  that  at  the  patient's  request,  the  treatment  was  discontinued.  Fortunately 
as  a  result  of  these  injections,  pyogenic  infection  ensued.  The  tumor  became  intensely  red  and 
swollen.  The  skin  did  not  have  the  glazed  appearance  of  erysipelas  although  deeply  injected. 
The  infection  proved  to  be  pyogenic  and  several  incisions  were  necessary  to  permit  the  free  dis- 
charge of  pus.  The  patient  became  much  exhausted  from  the  high  temperatures  and  septic 
absorption,  during  which  time  the  tumor  began  to  diminish  in  size  and  gradually  it  disappeared. 
This  patient  survived  eighteen  years  without  recurrence  and  until  a  few  days  before  his  death, 
from  acute  pneumonia,  was  in  the  enjoyment  of  robust  health,  his  weight  then  being  170  pounds. 
On  May  20,  1893,  a  gentleman  thirty-five  years  of  age  consulted  me  on  account  of  a  large  tumor 
occupying  the  right  hypochondriac  region.  He  had  been  tapped  for  dropsy  on  three  occasions  and 
I  removed,  by  measurement,  five  gallons  of  fluid  from  the  peritoneal  cavity.  With  the  collapse 
of  the  abdominal  wall,  a  hard,  round,  slightly  movable  tumor  with  a  transverse  and  antero- 
posterior diameter  of  about  six  inches  and  about  eight  inches  in  its  longest  measurement,  was 
made  out.  The  tumor  was  exposed  by  an  incision  about  six  inches  in  length.  It  was  firm  to  the 
touch  and  occupied  the  space  between  the  stomach  and  liver.  It  seemed  to  be  developed  from 
the  gastro-hepatic  omentum,  was  of  a  reddish-brown  color,  and  covered  in  front  with  a  network 
of  large  vessels.  The  abdominal  wound  was  dressed  so  as  to  permit  about  one  third  of  the  anterior 
surface  of  the  mass  to  present  in  the  wound,  with  sterile  gauze  inserted,  to  secure  adhesions  and 
prevent  general  peritoneal  infection.  Three  days  later  the  packing  was  removed  and  the  wound  and 
exposed  surface  of  the  tumor  were  permitted  to  become  infected.  Suppuration  rapidly  supervened. 
The  dressings  were  changed  daily  and  within  two  weeks'  time  there  was  a  marked  diminution 
in  the  size  of  the  mass.  The  wound  was  kept  open  and  allowed  to  suppurate  for  about  two  months, 
at  the  end  of  which  time,  as  well  as  I  could  estimate,  the  tumor  was  about  one-half  its  original  size. 
After  the  wound  healed  the  shrinkage  continued  and  at  the  end  of  six  months  the  swelling  had 
disappeared.  Tapping  was  only  necessary  once  in  six  weeks  after  the  treatment  was  begun. 
The  patient's  general  condition  improved  from  day  to  day  and  he  is  now,  fourteen  years  after  the 
oj)eration,  perfectly  well. 

-  The  cultures  used  are  those  which  have  been  prepared  by  Dr.  Buxton  of  the  Loomis  Labora- 
tory and  by  Dr.  F.  M.  Jeffries  of  the  Laboratory  of  the  New  "York  Polyclinic  Medical  School  and 
Hospital. 


NEOPLASMS  711 

1)6  thro-mi  partly  into  and  partly  beneath  the  skin,  and  the  dose  gradually  in- 
creased daily  until  a  localized  redness  is  present  or  until  a  marked  febrile  reac- 
tion— 101°  to  103°  F. — is  observed. 

In  a  certain  proportion  of  eases  it  is  impossible  to  obtain  a  reaction  with  the 
erysipelatous  toxine  until  the  resistance  of  the  patient  has  been  lowered  by  a  series 
of  injections  of  the  pyogenic  streptococcus. 

In  a  few  instances  the  author  has  employed  a  mixed  toxine  as  recommended 
by  Dr.  Coley  for  lowering  the  resistance  of  a  patient,  ia  order  to  secure  the  proper 
reaction  from  the  erysipelas  toxine. 

As  the  treatment  progresses  the  injections  can  be  carried  more  deeply,  and 
finally,  when  the  system  has  been  accustomed  to  its  presence,  the  agent  may  be 
thrown  into  the  substance  of  the  tumor.  The  author's  method  of  injection  after 
amputation  is  illustrated  in  the  following  case: 

In  an  amputation  through  the  thigh,  on  account  of  sarcoma,  the  woimd  healed 
promptly,  and  at  the  end  of  two  weeks  there  was  only  a  slight  discharge  through 
a  gauze  draia  in  one  angle  of  the  stump.  A  gauze  wicker  drain  was  saturated 
"with  the  cultures  of  pure  streptococcus  and  inserted  into  the  drainage  sinus.  The 
wound  became  red  and  swollen,  with  marked  exacerbations  of  temperature.  Feh- 
leisen's  coccus  was  substituted  at  the  end  of  two  weeks,  and  two  weeks  later  the 
pure  streptococcus  pj'ogenes  was  employed.  This  treatment  was  discontinued  after 
six  weeks  and  the  woimd  allowed  to  heal.  Two  years  have  elapsed,  and  with  no 
suggestion  of  recurrence.  This  is  the  teclmic  advised  in  all  cases  of  amputation. 
On  account  of  the  large  exposed  surface  in  an  amputation  through  the  thigh, 
together  with  the  shock  of  an  operation,  it  is  deemed  advisable  to  postpone  infec- 
tion imtil  the  wound  has  practically  healed. 

In  addition  to  these  cases,  and  others  in  the  author's  experience.  Dr.  W.  B. 
Coley  has  reported  a  number  of  successfid  results  following  infection  with  the 
mixed  toxins.     The  preparation  of  this  agent  as  given  by  him  is  as  follows :  ^ 

"  Streptococcus  culture  in  broth — three  weeks'  growth 100  c.e. 

Prodigiosus  suspension,  containing  750  milligrams  of  pro- 

digiosus  proteid    30    " 

Glycerine    20    " 

"  Each  cubic  centimeter  of  the  mixture  contains  5  milligrams  of  the  prodigio- 
sus proteid.  Considering  1  oz.  to  be  equal  to  29.5?  c.c,  it  contains  147.85  milli- 
grams prodigiosus  proteid;  1  c.c.  equals  about  17  minims,  so  1  minim  contains 
about  3  milligranis  of  prodigiosus. 

"  The  prodigiosus  suspension  used  is  made  and  measured  in  the  following  way : 
Prodigiosus  is  grown  on  agar  for  ten  days.  There  is  then  a  thick  red  growth, 
which  is  scraped  off  with  glass  rods  and  rubbed  up  with  a  mortar  and  pestle  to 
-a  smooth,  rather  thick  suspension,  using  physiological  salt  solution  as  diluent. 
This  suspension  is  sterilized  by  heat — one  hour  at  75°  F.  The  total  nitrogen  per 
c.c.  is  determined  and  the  weight  of  nitrogen  per  c.c.  multiplied  by  the  factor 
6.25  gives  the  weight  of  proteid  present.  Thus  the  weight  of  prodigiosus  proteid 
in  each  c.c.  is  known  and  the  suspension  is  diluted  to  the  required  strength  before 
mixing  with  the  streptococcus  culture.  After  mixing  and  bottling  the  toxines,  the 
mixture  is  again  sterilized  two  hours  at  75°  F." 

Dr.  Colej"  insists  that  it  "  is  most  important  to  begin  in  everj'  case  with  a  very 
small  dose,  not  over  one  quarter  minim  (diluted  with  a  little  boUed  water  to 
insure  accuracy  of  dosage).  If  the  tumor  in  question  is  highly  vascular,  it  is  wiser 
to  begin  the  injections  remote  from  the  same,  imtil  the  susceptibility  of  the  patient  ■ 
to  the  toxines  has  been  ascertained.  Tliis  varies  considerably  in  different  indi- 
viduals.   After  a  few  doses  it  is  safe,  in  most  cases,  to  inject  into  the  tumor  itself. 

"  As  a  rule,  when  giving  injections  into  the  tumor,  only  about  one  fifth  of  the 
dose  used  for  injections  remote  from  the  timior  is  required  to  produce  the  same 
reaction.  The  dose  should  be  increased  by  one  quarter  minim  when  given  into  the 
iumor;  by  one  half  minim  when  injected  remote  from  the  tumor,  until  the  desired 

1  "Medical  Record,"  July  27,  1907. 


712  NEOPLASMS 

reaction  is  obtained.  The  best  results  are  obtained  by  doses  sufficiently  large  to 
produce  severe  reactions,  say  a  temperature  of  102°  to  105°  F. 

"  The  frequency  of  the  injections  must  depend  entirely  upon  the  strength  of 
the  patient,  some  being  able  to  bear  daily  injections,  while  in  others  it  may  be 
unwise  to  push  the  treatment  beyond  three  or  four  injections  a  week. 

"  In  the  successful  cases  the  effect  is  usually  very  promptly  noticeable.  The 
tumor  becomes  smaller  in  size,  much  more  movable,  and  very  much  less  vascular. 
These  changes  appear  very  quickly,  often  within  two  to  three  days. 

"  The  action  of  the  toxines  is  both  local  and  systemic.  Sometimes  the  best 
results  are  obtained  by  giving  the  injections  alternately  into  the  tumor  and  remote 
from  the  same.  In  tumors  in  inaccessible  regions — e.  g.,  intra-abdominal  sarcoma 
or  sarcoma  of  the  tonsil — a  perfect  cure  may  be  oljtained  entirely  by  systemic 
injections."  ^ 

NON-MALIGKANT    NEOPLASMS 

The  non-malignant  epitheliomata  are  the  dry,  pavement,  or  pearl-like  epitheli- 
oma, papilloma,  the  adenoma,  and  the  cystic  tumors. 

The  pearl  epithelioma  is  of  rare  occurrence.  Microscopically,  it  is  found  to  be 
closely  akin  to  the  bird's-nest  tumors,  which  are  classed  with  the  malignant 
growths.  The  cells  of  the  non-malignant  and  rare  neoplasm  are,  however,  flat, 
and  collected  in  little  dry,  pearl-like  bodies,  gathered  in  clusters,  and  held  together, 
or  surroimded  by  a  connective-tissue  stroma.  Occasionally,  cholesterine  crystals  are 
seen  in  these  bodies,  and  tliis  fact  induced  iliiller  to  name  this  form  of  neoplasm 
"  cholesteatoma." 

The  proper  treatment  is  removal  ■n'ith  the  knife,  or  Marsden's  paste. 

Papilloma. — A  papilloma  is  a  neoplasm,  in  structure  not  imlike  the  normal 
papillffi  of  the  skin  and  mucous  membranes.  Each  papilla  possesses  a  connective- 
tissue  framework  which  supports  one  or  more  new-formed  vascular  loops,  and  the 
whole  is  covered  in  with  one  or  several  layers  of  epithelia. 

They  may  be  met  with  upon  the  cutaneous,  mucous,  or  serous  surfaces. 

The  most  frequent  form  of  papilloma  is  the  ordinary  "  wart."  The  hard  or 
cutaneous  wart  is  often  seen  upon  the  hands ;  the  soft  or  mucous  wart  is  frequently 
met  with  upon  the  prepuce,  vulva,  and  anal  margins.  Corns  are  also  classified 
as  papillomata. 

Mucous  warts  grow  more  exuberantly  than  those  of  the  skin.  Upon  the  pre- 
puce, where  they  are  kept  moist  and  are  subjected  to  irritating  secretions  and  to 
friction,  they  form  at  times  enormous  masses.  Haemorrhage  is  a  common  accident, 
and  sloughing,  with  the  emission  of  a  most  offensive  odor,  is  the  rule  in  these 
larger  neoplasms. 

Essentially  benign  papillomata  may,  by  long-continued  irritation,  be  converted 
into,  or  replaced  by,  an  embryonic  neoplasm  of  a  malignant  type. 

Treatment. — The  indication  is  to  destroy  them  at  once.  The  best  method  to 
pursue  is  to  grasp  them  with  forceps,  clip  them  off  with  scissors  close  to  the  at- 
tached margin,  and  apply  nitric  acid  to  the  bleeding  base  of  the  neoplasm.  Anes- 
thesia is  obtained  by  moistening  them  for  several  minutes  with  a  four-per-cent 
solution  of  cocaine  hydrochlorate.  The  nitric  acid  leaves  a  yellow  stain,  which  is 
objectionable  when  the  growth  is  situated  upon  an  exposed  surface. 

Adenoma. — Adenomata  are  neoplasms  the  striicture  of  which  is  analogous  to 
gland  tissue.  Following  this  analogy,  they  are  of  the  racemose  and  tubular  vari- 
eties. The  racemose  adenomata  are  extremely  rare.  They  are  comijosed  of  collec- 
tions of  acini  held  togetlier  by  a  varying  quantity  of  connective  tissue,  and  lined 
with  epithelium.  They  may  develop  in  all  parts  of  tlie  economy  where  the  race- 
mose glands  are  found.  A  favorite  location  is  the  mammary  gland,  occasionally 
the  parotid,  the  lachrymal  gland,  and  the  roof  of  the  mouth.  They  are  slow  in 
growth,  are  spherical  in  shape,  and  are  freely  movable  in  the  structure  in  which 
they  develop. 

Tubular  adenoma  is  more  frequently  observed  than  the  racemose  variety.     The 

'  It  is  advisable  to  obtain  the  toxine  as  prepared  in  the  laboratory. 


NEOPLASMS 


713 


tubules  are  in  some  cases  separated  by  a  layer  of  new-formed  connective  tissue, 
while  in  others  there  is  no  perceptible  intertubiilar  stroma.  The  tubules  may  be 
single,  but  are  more  frequently  bifurcated,  and,  as  in  the  normal  glands,  com- 
mence in  blind  extremities  and  open  upon  the  mucous  surface.  They  are  lined 
with  one  or  more  layers  of  glandular  epithelium.  These  tumors  are  seen  in  the 
rectum  and  colon,  in  the  uterus,  especially  the  cervix,  and  occasionally  in  the  nose 
(Fig.  746). 

They  are  spherical  or  pyriform  masses,  covered  with  mucous  epithelium  as  long 
as  they  are  conta    e  1  witl  n  tl  e  ca    t        b  t  \\  1  en   1 }  rea  on  of  e\ce     ve  growth, 


FiG.  746  — Na  al  po   ^u        a  Pa  ement  ep   he  a  of  w  e  deepe   lay        rf  a  e    y  nd     al,  and  are 

arranged  along  the  edges  of  the  papillae,  h.     A  vessel  is  shown  at  b.     (After  Cornil  and  Ranvier.) 

they  are  exiDosed  to  the  air,  the  covering  becomes  hard  and  smooth,  like  the 
epidermis. 

Cysts. — A  cyst  is  a  tumor  composed  of  a  limiting  membrane  or  capsule  of  con- 
nective tissue,  lined  by  epithelium  and  iilled  with  fluid  or  semifluid  contents.  The 
contained  matter  may  be  mucoid  or  colloid  material,  or  sebaceous  matter  and  epi- 
thelial cells  in  varioits  conditions  of  degeneration. 

Setaceous  cysts  occur  upon  all  portions  of  the  external  surface,  and  in  rare 
instances  develop  in  the  deeper  tissues. 

The  external  sebaceous  tumors  are  seen  very  frequently  upon  the  face  and 
scalp,  and  vary  in  size,  measuring  at  times  an  inch  or  more  in  diameter.  They 
are  spherical  or  flattened  tumors,  soft  and  elastic  to  the  touch,  and  freely  movable 
upon  the  subcutaneous  tissues. 

The  contents  may  be  a  white,  cheesy  matter  or  more  fluid,  and  of  an  amber 
or  brown  color.  Examined  microscopically,  it  is  seen  to  be  composed  of  epithelial 
cells  which  have  undergone  a  more  or  less  complete  granular  metamorphosis,  loose 
granules,  compound  granular  corpuscles,  cholesterine  crystals,  rudimentary  hairs, 
etc.  The  wall  of  the  cyst  varies  in  thickness,  being  at  times  very  thin  and  closely 
adherent  to  the  surrounding  structures,  and  at  others  thick  and  easily  detached. 
Those  upon  the  hairy  scalp,  commonly  known  as  "  ivens"  are  usually  filled  with 
an  amber-colored,  jellylike  mass,  which  escapies  upon  section  or  punctitre  of  the 
cyst.  Upon  the  face,  or  other  cutaneous  surface,  the  contents  are  apt  to  be  cheesy 
in  character. 

They  are  caused  by  cell-proliferation  and  the  accitmulation  within  the  hair- 
follicle  and  communicating  sebaceous  gland  of  its  normal  secretion,  which  cannot 
escape,  owing  to  the  partial  or  complete  occlusion  of  the  excretory  duct.  Cutane- 
ous cysts,  from  direct  violence,  and  often  without  any  appreciable  cause,  may 
inflame  and  suppurate.  _  _    - 

Dermoid  cysts  are  closely  analogous  to  the  preceding,  although  situated  in  the 
deeper  structures.    They  consist  of  a  limiting  membrane,  and  liquid  and  solid  con- 


714  NEOPLASMS 

tents.  In  addition  to  the  changed  epithelial  cells  and  granular  matter,  these  tumors 
often  contain  tufts  of  hair,  rudimentary  teeth,  etc.  They  occupy  by  preference  the 
ovary,  but  are  met  with  in  all  parts  of  the  body. 

Mucous  cysts  are  usually  seen  upon  the  lips,  buccal  cavity,  vulva,  and  anus. 
They  may  occur  in  any  portion  of  the  alimentary  or  respiratory  passages,  or  in 
any  of  the  cavities,  lined  by  mucous  meml^rane.  The  wall  is  thin,  lined  with 
epithelium,  and  adhering  to  the  surrounding  structures.  The  contents  are  a  viscid 
mucus,  resembling  the  white  of  an  egg.  The  cause  of  the  tumor  is  obstruction  of 
the  normal  excretorj^  duct.  The  character  of  the  tumor  may  be  suspected  from  the 
location  and  the  spherical  shape.  A  slight  puncture,  with  compression,  will  reveal 
the  mucous  character  of  the  contents. 

Serous  Cysts. — Cysts  of  the  smaller  serous  cavities  may  result  from  hypersecre- 
tion of  the  normal  fluid  by  the  epithelia  lining  the  serous  membrane,  in  which  the 
excess  is  not  reabsorbed.  The  swellings  often  observed  upon  the  back  of  the  wrist 
and  hand,  and  sometimes  upon  the  dorsal  aspect  of  the  foot,  are  typical  serous 
cysts,  and  result  from  hyperdistention  of  normal  serous  bursse. 

Lipoma. — A  fatty  tumor  is  a  circumscribed  collection  of  adipose  tissue  growing 
independently  of  the  other  tissues.  Lipomata,  usually  develop  in  the  subcutaneous 
cellular  tissue,  and  are  frequently  met  with  about  the  back  of  the  neck  and  shoul- 
ders. From  this  location  they  occasionally  are  carried  by  gravity  toward  the  sa- 
crum, slipping  downward  between  the  integument  and  deep  fascia.  Situated  super- 
ficially, they  grow  to  be  irregular  and  S]3herical  or  pyriform  tumors  of  varying 
size;  are  usually  single,  but  may  be  multiple.  Less  often  they  are  met  with  in 
the  glands,  muscles,  bones,  and  in  the  abdominal  viscera. 

llicroscopically,  they  are  composed  of  vesicles  filled  with  oil  or  fat.  The  vesi- 
cles are  connective-tissue  corpuscles,  the  nuclei  of  which  are  displaced  to  the  periph- 
ery and  compressed  against  the  investing  membrane  of  the  vesicle.  These  vesicles 
are  held  together  in  clusters  of  various  size  by  a  stroma  of  fibrous  tissue,  in  the 
meshes  of  which  the  blood  vessels  run.     The  whole  tumor  is  in  turn  encapsuled. 

Various  names  have  been  given  to  certain  complex  fatty  tumors;  when  the 
intervesicular  substance  is  myxomatoiis,  myxo-Iipoma;  when  the  connective  tissue 
is  excessive,  fibro-lipoma ;  in  bone,  osteo-lipoma;  when  very  vascular,  angeio-lipo- 
ina,  etc. 

Lipomata  may  undergo  granular  and  calcareous  metamorphosis,  and  may  also 
become  inflamed  and  break  down  as  a  very  offensive  and  sloughing  mass.  They 
are  altogether  benign,  and  can  only  cause  death  by  ulceration,  sepsis,  and  hsemor- 
rhage,  or  by  pressure  upon  important  organs. 

The  diagnosis  depends  upon  tlie  soft,  uneven  feel  and  the  mobility  of  the  mass. 
It  is  only  to  be  differentiated  from  old  abscesses  or  cystic '  tumors.  If  the  history 
does  not  point  to  the  diagnosis,  the  aspirator  needle  will  be  of  service. 

The  treatment  is  removal  with  the  knife.  The  incision  may  be  straight  for  a 
small  tumor,  but  should  be  elliptical  for  large  growths,  in  order  to  do  away  with 
redimdancjf  after  the  tumor  is  turned  out.  The  capsule  should  be  opened,  and  the 
tumor  may  be  turned  out  almost  whollj'  with  the  fingers. 

Fibroma. — This  variety  of  neoplasm  is  made  up  of  fibrous  tissue,  the  filaments 
of  which  are  at  times  arranged  in  bundles  which  run  in  all  directions;  at  others, 
there  is  little  or  no  fascicular  arrangement,  the  filaments  being  entangled  in  all 
directions.  In  the  interstices  of  the  bundles,  or  between  the  fasciculi,  are  found 
connective-tissue  cells,  the  poles  of  which  commimicate  with  each  other.  The 
vascular  supply  is  limited.  Fibromata  develop  chiefly  in  the  skin  and  subcu- 
taneous tissues  and  j)eriosteum,  but  maj^  exist  in  any  other  portion  of  the  body. 
They  are  usuall}^  single  and  small,  occasionallj'  multiple,  and  this  form  of  tu-. 
mor  may  attain  an  enormous  size.  In  shape,  those  developing  from  the  deeper 
tissues  are  spherical,  and  are  hard  to  the  touch.  In  the  skin  they  are  often 
pedunculated  and  pyriform.  Fibromata  may  undergo .  a  mucoid,  granular,  or 
calcareous  degeneration,  and  are  subject  to  inflammation  and  suppuration,  as  are 
other  neoplasms.  Possessing  a  low  degree  of  vascularity,  the  danger  of  hemor- 
rhage is  not  great,  unless  a  rich  granulation  tissue  has  sprung  up  as  a  result  of 
prolonged  irritation. 


NEOPLASMS  715 

Simple  fibroma  is  benign,  and  the  indications  in  treatment  are  removal  by  the 
knife. 

Myxoma. — This  neoplasm  is  made  up  of  primitive  connective-tissue  cells,  simi- 
lar to  those  observed  in  the  umbilical  cord  at  birth.  The  cell  elements  are  spherical 
and  fusiform  in  shape.  The  former  are  isolated  and  float  freely  in  the  gelatinous- 
like  intercellular  substance.  The  latter  may  possess  two  or  more  poles,  and  anas- 
tomose freely  with  each  other,  forming  a  continuous  network  or  stroma  through- 
out the  mass.  The  vascular  supply  is  rich.  These  neoplasms  occur,  as  a  rule,  in 
the  skin  and  subcutaneous  tissues  and  upon  the  mucous  surfaces,  especially  in  the 
nose  (mucous  or  soft  polypi).  They  may  develop,  however,  in  any  portion  of  the 
body,  and  have  been  observed  in  the  muscles,  bones,  and  nerves,  the  mammary 
gland,  kidnc)',  brain,  etc.  In  shape  they  are  usually  spherical,  of  small  size,  and 
are  soft  and  doughy  to  the  touch,  and  not  painful  unless  by  accident  the  sensory 
nerves  are  pressed  upon  by  the  tumor.  As  a  result  of  rupture  of  the  blood  vessels, 
cysts  frequently  occur  in  this  variety  of  neoplasm. 

The  treatment  is  early  and  complete  removal.  Pure  myxoma  does  not  tend  to 
recur  after  a  thorough  removal.  In  some  instances,  owing  to  the  peculiar  location 
of  the  neoplasm,  a  thorough  extirpation  is  impossible,  and  in  these  cases  the  tumor 
may  rapidly  recur.  The  cases  of  general  metastasis  after  supposed  myxoma  were 
probably  instances  in  which  the  sarcomatous  nature  of  the  growth  had  been  over- 
looked. 

Myoma  is  a  tumor  composed  of  new-formed  muscular  elements.  There  are 
two  varieties,  namely,  those  composed  of  striated  or  voluntary,  and  those  of  non- 
striated  or  involuntary  muscular  fibers. 

The  first  variety  is  extremely  rare,  and  is  of  less  clinical  importance  than  the 
non-striated  myoma. 

In  two  instances  the  striated  myoma  has  been  seen  in  a  congenital  tumor  of  the 
testicle,  and  in  a  few  other  instances  of  tumors  developed  wholly  or  in  part  in  the 
embryo  or  foetus.     Dermoid  cysts  at  times  contain  traces  of  striated  muscle. 

A  diagnosis  can  only  be  made  out  b_y  the  recognition,  under  the  microscope,  of 
the  characteristic  striated  muscular  fiber.  The  jjrognosis  is  favorable,  owing  to  the 
benign  nature  of  the  tumor,  which,  nevertheless,  should  be  removed  as  soon  as 
recognized. 

In  the  non-striated  myoma  the  fusiform  elements  are  arranged  in  all  directions, 
either  in  bundles  or  groups  which  interlace,  or  there  may  be  a  general  interlacing 
of  the  separate  elements  without  fascicular  arrangement,  as  in  many  of  the  organs 
in  which  the  smooth  muscle  is  found.  Between  these  bundles  true  connective-tissue 
cells  exist,  and  in  these  spaces  the  vessels  are  found.  The  nuclei  of  these  new- 
formed  elements,  as  well  as  the  muscle-elements  proper,  do  not  differ  materially 
from  the  normal  non-striated  muscular  fibers. 

ISTon-striated  myomata  are  often  met  with  in  the  uterus.  In  many  of  these 
neoplasms  there  is  a  variable  quantity  of  connective  tissue,  more  or  less  organized, 
and  for  this  reason  the  term  fibro-myoma  has  been  given  to  these  tumors.  They 
may  grow  from  the  wall  of  the  uterus,  toward  the  peritonaeum  {extramural),  or 
develop  in  the  substance  of  the  uterine  muscle,  become  encapsuled  (intermural) , 
or  project  from  tlie  internal  surface  into  the  cavity  of  this  organ  (submucous 
myoma,  intramural). 

This  variety  of  neoplasm  has  also  been  seen  in  various  other  localities,  as  the 
skin,  alimentary  canal  at  various  points,  the  prostate,  scrotum,  etc.  The  diagnosis 
depends  upon  the  recognition  of  the  characteristic  fusiform  elements  under  the 
microscope.  The  method  advocated  by  Cornil  and  Eanvier  is.  to  macerate  the  sec- 
tions in  azotic  acid,  twenty  parts  to  one  hundred  of  water,  or  caustic  potassa,  forty 
parts  to  one  hundred  of  water.  By  this  process  the  connective-tissue  stroma  is 
dissolved  and  the  muscular  elements  liberated. 

The  prognosis  in  this  form  of  myoma  is  favorable  as  far  as  recurrence  is  con- 
cerned when  the  removal  has  been  thorough.  They  not  infrequently  produce  death, 
either  directly  by  pressure  and  interference  with  the  normal  functions  of  organs 
necessary  to  life,  or  indirectly  by  causing  hfemorrhage,  rendering  the  individual 
more  likely  to  perish  from  some  intercurrent  affection. 


716 


NEOPLASMS 


Treatment. — They  should  be  removed,  when  this  can  be  done  with  a  justifiable 
degree  of  safety. 

Neuroma.— A.  tumor  composed  of  new-formed  nerve  tissue  is  rarely  met  witli. 
Many  so-called  neuromata  are  connective-tissue  neoplasms  springing  from  the  neu- 
rilemma. They  may  be  made  up  of  nerve  cells  or  nerve  fibers  (Fig.  7-17). 

The  former  are  even  rarer  than  the  latter.  Small  particles  of  gray  matter  have 
been  seen  in  dermoid  cysts,  and  in  a  few  instances  neoplasms  of  this  variety  have 
been  seen  in  the  brain  and  spinal  cord. 

Fascicular  neuromata  may  occur  in  the  nerves.  They  exist  as  slight  elliptical 
swellings  or  enlargements  of  the  nerve  involved,  may  be  single,  or  there  may  be 
a  succession  of  nodosities  in  the  course  of  the  nerve. 

The  symptoms,  in  addition  to  the  tumor,  which  may  at  times  be  made  out 
by  palpation,  are  those  of  piain  or  interference  with  the  function  of  the  part  in- 
volved. A  careful  analysis  with  the  microscope  alone  can  determine  an  accurate 
diagnosis. 

The  prognosis  is  not  grave,  in  so  far  as  the  life  of  the  patient  is  concerned, 
but  the  removal  of  the  neoplasm  may  of  necessity  involve  an  injury  of  the  trunlc 
in  or  upon  which  it  is  located,  and  in  this  manner  may  add  an  element  of  gravity 
to  the  result.  They  should  be  extirpated,  and,  Avhere  (as  will  almost  always  be 
the  case)  the  positively  benign  character  of  the  neoplasm  is  not  evident,  a  section 

of  the  nerve  below  and  above  the  tumor, 
as  well  as  a  portion  of  the  surrounding 
m  /    I      tl  11    '      /  ;         tissiies,  should  be  removed. 


Fig.  747. — Neuromata  developed  in  the  divided 
nerve  tissues  after  amputation  of  tlie  member. 
(After  Cornil  and  Ranvier.) 


Fig.  748  — Angeioma  (cirsoid  aneurism)  of  the 
temporal  region. 


Angeioma. — The  angeiomata  are  tumors  of  new-formed  vessels,  capillaries,  ar- 
terioles, or  veins.  They  are  frequently  congenital,  and  may  also  appear  at  any 
period  after  birth. 

Microscopically,  the  simple  forms  are  made  up  of  capillaries,  arterioles,  and 
veinules  in  plexuses  richer  than  the  normal,  and  held  together  by  a  connective- 
tissue  stroma  of  varying  thickness.  In  the  more  formidable  tumors — cavernous 
nwvi — the  vessels  are  larger,  with  thickened  walls  of  dense  connective  tissue,  and 
at  times  a  quantity  of  non-striated  muscular  fibers.  The  vasa  vasorum  are  also 
met  with  in  the  walls  of  the  sinuses. 

The  former  variety  appear  as  red  or  bluish  spots  or  stains  in  the  skin,  of  vari- 
ous sizes  and  shapes,  at  times  rising  above  the  level  of  the  integument. 

The  method  of  treatment  is  fully  described  in  the  chapter  upon  diseases  of 
the  vascular  system. 

Lymphangeioma. — Tumors  composed  of  new-formed  lymphatic  vessels  are 
very  rarely  met  with.     In  their  construction  they  do  not  materially  differ  from 


NEOPLASMS  717 

the  angeiomata.  The  new  tissue  consists  of  a  capillary  network  of  lymph 
channels,  in  arrangement  analogous  to  the  capillary  vessels  in  the  smaller  an- 
geiomata. 

In  the  case  shown  in  Fig.  7-19  I  removed  by  dissection  a  plexus  of  lymphatic 
vessels  about  as  large  as  a  hen's  egg.  The  walls  were  sacculated,  and  the  vessels 
were  distended  with  clear  lymph.  Situated  in  the  cheek,  this  form  of  tumor  may 
be  mistaken  for  retention  of  parotid  secretion  due  to  stricture  of  Steno's  duct  or 


Fig.  749. — Lymphangeioma  of  left  buccal  wall. 

its  occlusion  by  calculi.  In  other  instances  the  lymph  canals  have  a  cavernous 
arrangement  comparable  to  the  structure  of  the  cavernous  nsevus  described  in  the 
article  on  vascular,  tumors. 

Lymphadenoma. — Many  forms  of  enlargement  of  the  lymphatic  glands  are  not 
true  tumors,  since  they  are  not  composed  of  new-made  gland  tissue,  but  are  due 
to  cancerous  infiltration,  to  tubercle,  to  syphilitic  adenitis,  tubercular  deposit,  etc. 
Tubercular  lymphomata  should  always  be  extirpated  when  tuberculosis  of  the  deeper 
organs  can  be  excluded,  provided  that  the  operation  of  removal  does  not  involve 
a  too  great  risk  of  life.  The  removal  of  enlarged  glands  from  metastasis  in  cancer 
should  also  be  done  when  there  is  a  reasonable  hope  of  cutting  off  the  disease 
from  the  centers. 

Chondroma. — New  formations  of  cartilage  develop  in  and  from  the  connective- 
tissue  cells  of  any  portions  of  the  body,  excepting  from  cartilage  proper.  The 
bones  and  periosteum  are  favorite  points  of  origin  for  these  neoplasms.  Develop- 
ing from  within  the  bone,  a  cartilaginous  new  formation  is  termed  an  enchon- 
droma;  if  from  the  periosteum,  a  pericliondroma.  Quite  a  number  of  chondromata 
have  been  observed  in  the  testicles  and  in  the  parotid  glands.  They  may  assume 
all  sorts  of  shapes,  growing  into  more  or  less  spherical  tumors,  or  the  new  tissue 
may  be  generally  diffused  in  the  normal  tissue. 

In  the  bones  of  the  hand  and  fingers  they  give  rise  to  marked  deformities  and 
to  considerable  pain,  from  displacement  of  the  normal  structures  and  interference 
with  nutrition  (Fig.  750). 

The  new  formation  of  cartilage  is  preceded  by  an  inflammatory  jn-ocees  varying 
in  intensity,  usually  of  a  mild  nature,  yet  resulting  in  the  proliferation  of  the 
cells  of  the  part  involved,  and  the  formation  of  an  embryonic  tissue  from  which 
the  cartilage  is  formed,  as  in  the  normal  development  of  this  tissue.     Some  of 


718 


NEOPLASMS 


these  cells  become  the  cartilage  cells  proper,  and  are  collected  in  groups  of  differ- 
ent sizes,  while  others  form  a  connective-tissue  stroma  around  the  collections 
of  cartilage  cells.  The  vessels  find  their  way  along  these  bundles  of  connective 
tissue. 

The  proportion  of  connective-tissue  stroma  varies  in  different  tumors.  When 
the  cartilage  cells  and  groups  are  plentiful,  with  a  limited  c|uantity  of  intervening 
fibrous  tissue,  the  mass  is  strictly  a  chondroma.  When  the  stroma  preponderates, 
it  is  termed  a  fibro-chondroma.  In  certain  forms  of  these  tumors  there  is  a  paucity 
of  connective-tissue  fibers  as  well  as  cartilage  cells,  although  both  are  present  in 
quantity  sufficient  for  recognition.  The  mass  of  tissue  may  be  embryonic,  and, 
under  such  conditions,  the  tumor  may  be  sarcomatous  in  character.     Simple  chon- 


FiG.  750. — Diffuse  chondroma  of  the  phalanges  and 
metacarpal  bones.     (After  Nelaton.) 


droma  is  benign,  but  a  mixed  chondroma  of  an  embryonic-tissue  type  must  be 
classed  with  the  malignant  neoplasms. 

Chondromata  may  undergo  fatty  or  granular  degeneration,  may  ossify  in  part, 
ma}'  become  infiltrated  with  calcareous  matter,  or  undergo  the  mucoid  change. 

Treatment. — Eemoval  is  indicated  when  jjain  is  unbearable,  or  when  the  sar- 
comatous nature  of  the  neoplasm  is  evident. 

Osteoma. — Tumors  of  new-formed  bone  tissue  ma}'  develop  from  the  normal 
bone  and  periosteum,  or  in  the  tissues  removed  from  the  bones.  There  are  three 
varieties — the  eburnated,  compact,  and  spongy. 

In  the  first,  or  ivorylike  neoplasms,  the  bone  is  exceedingly  dense  and  hard, 
and  contains  bone  corpuscles  and  canaliculi,  which,  though  well  marked,  are  more 
irregular  in  arrangement  than  in  normal  forms.  This  new-formed  bone  tissue, 
however,  does  not  possess  blood  vessels.  These  tumors  are  especially  apt  to  be 
observed  upon  the  bones  of  the  skull,  notably  those  of  the  frontal  and  parietal 
regions. 

The  compact  or  spongy  neoplasms  are  in  structure  analogous  to  the  normal 
compact  or  spongy  bone  substance.  In  the  latter  the  bony  framework  is  light, 
and  the  medullary  spaces  larger  than  normal. 

An  osteoma  formed  upon  the  outside  of  an  old  bone  is  called  an  exostosis;  de- 
veloped within  the  medullary  space,  an  enostosis. 

Exostoses  grow  as  more  or  less  well-rounded  tumors  beneath  the  periosteum, 
or  as  sharp  spikes  or  thorns  projecting  from  the  bone.  Such  spines  are  in  the 
great  majoritj'  of  instances  directed  upward  (stalagmites)  in  the  axis  of  the  tendon 
in  and  about  which  they  develop.  In  rare  instances  the  direction  is  do-ivnward 
(stalactite). 

Bony  neoplasms  may  also  develop  in  any  of  the  cartilaginous  tissues  of  the 
bod}',  and  this  change  is  usually  one  of  senility.     Beyond  this,  bone  may  form  in 


XEOPLASMS  719 

the  muscles^  choroid,  the  serous  membranes  in  all  locations,  and  in  the  integii- 
ment. 

Osteomata  are  always  benign.  If  dangerous  at  all,  it  is  from  compression 
of  important  organs.  Those  developed  from  the  internal  surface  of  the 
cranial  bones  and  along  the  vertebral  canal  are  espeeialW  dangerous  in  this 
respect. 

Treatment. — Interference  is  not  called  for,  imless  pressure  upon  important 
organs  renders  it  necessary. 

Keloid. — Keloid,  a  formation  of  scar  tissue  either  resulting  from  a  traumatism 
— i.  e.,  in  the  scar  of  a  wound  which  is  healing — or  without  any  apparent  cause, 
is  frequently  met  with  in  surgical  practice.  According  to  A.  E.  Eobinson,  it  is  a 
circumscribed  connective-tissue  new  growth  of  the  skin  characterized  by  the  appear- 
ance of  one  or  more  irregular,  elevated,  firm,  smooth,  reddish,  somewhat  elastic 
tumors.  The  cause  of  keloid  is  not  as  yet  understood.  It  is  a  connective-tissue 
proliferation  of  peculiar  type,  which,  as  the  process  of  fibrillation  goes  on,  occludes 
the  vasctdar  supply  of  the  part,  and  yet  not  to  such  a  degree  as  to  cause  retrograde 
changes  or  absorption  of  the  new  tisstte.  Tramuatic  or  false  keloid  is  elevated 
from  one  eighth  to  one  fourth  or  one  half  inch  above  the  level  of  the  surroruiding 
skia,  and  usuallj'  assumes  the  shape  of  the  scar  in  which  it  has  developed,  while 
true  keloid  begins  as  a  small  nodule  situated  in  the  skin,  becoming  multiple  in 
almost  all  cases.  As  a  rule,  these  nodides  develop  to  a  certain  size,  growing  for 
two  or  three  years,  then  seem  to  reach  their  limitations  and  remain  stationary  for 
an  indefinite  period.  Occasionalh'  the}'  undergo  atrophy,  but  this  is  the  exception; 
they  iTsually  last  for  life. 

Treatment. — The  treatment  of  keloid  is  one  of  the  discouraging  features  of  sur- 
gical practice.  It  is  almost  always  an  incurable  disease,  but  rarely,  if  ever,  destroys 
life.  Sometimes  the  tumors  disappear  tinder  the  application  of  adhesive  straps, 
which  catise  at  least  temporary  atrophy,  and  the  same  result  has  been  noticed  in 
some  tumors  tmder  the  persistent  application  of  flexible  collodion.  Dr.  J.  W.  White 
reports  a  case  of  a  young  girl  who  received  a  lacerated  wound  of  the  face  from 
broken  glass.  A  disfiguring  keloid  developed  in  the  cicatrix.  All  treatment  was 
futile  until  she  was  given  daily  tn-o  to  four  doses  each  of  five  grains  of  thjToid 
extract.  The  scar  was  covered  with  a  film  of  collodion  to  protect  it  from  abrasions 
and  to  keep  up  gentle  pressure.  In  six  weeks  the  scar  in  its  entire  length  had 
come  down  to  the  level  of  the  skin,  where  it  remained.  The  improvement  seemed 
to  be  permanent. 

I  have  removed  these  tumors  in  several  instances,  extirpating  the  skin  and 
subcutaneous  connective  tissues  freely  away  from  the  neoplasm,  but  recurrence  took 
place  ia  each  case. 

{From  Park's  "Surgery") 
Table  1. — DirrEPLEXTiATiox  between  Bexigx  and  Maligxaxt  Gkowths 

Benign  Growths  Jilalignant   Growths 

Common  at  all  ages.  Eare  in  early  life. 

Usually  slow  in  growth.  Usually  rapid  in  growth. 

Xo  evidences  of  infiltration  or  dissem-  Infiltration  in  all  cases,  dissemination 
ination.  in  many. 

Are  often  encapsulated,  nearly  always  Xever  encapsulated,  seldom  circum- 
circumscribed.  scribed. 

Earely  adherent  unless  inflamed.  Always  adherent. 

Earelv  ulcerate.  Often    ulcerate  —  nearly    always    when 

surface  is  involved. 

Overlying  tissue  not  retracted.  Overlying  tissue  nearly  always  retracted. 

Xo  h-mphatie  involvement  when  not  in-  L}Taphatie  involvement  an  almost  con- 
flamed.  ?tant  feature. 

Xo  leucocytosis.  Leucocytosis  often  marked. 

Elimination  of  urea  imaffected.  Deficient  elimination  of  urea  (?). 


720 


NEOPLASMS 


Table   2. — Diagnosis  between   Sarcoma  and   Carcinoma 


Sarcoma 

Occurs  at  any  age. 

Disseminates     by     the     blood     vessels 

(veins). 
Arises  from  mesoblastic  structures. 

Distant  metastases  are  more  common. 
Contains    blood    channels    rather    than 

complete  blood  vessels. 
Less  prone  to  ulceration. 
Involvement  of  adjacent  lymphatics  not 

common. 
Secondary    changes    and    degenerations 

are  more  common. 
(Sugar  present  in  the  blood?) 


Carcinoma 

Kare  before  thirtieth  year  of  life. 
Disseminations  by  the  lymphatics. 

Arises  from  glandular   (epithelial)   tis- 
sues. 
Less  so. 
Contains  vessels  of  normal  type. 

More  so. 

Almost  invariably  adjacent  lymphatics 
are  involved. 

Degenerations  not  common;  other  sec- 
ondary changes  are. 

(Peptone  present  in  the  blood?) 


Table  3. — Diagnosis  between  Epithelioma  and  Tuberculosis   (Lupus) 


Epithelioma 
Preceded  usually  by  continued  irritation 

or  warty  growths. 
Diathesis  plays  no  known  part. 

Earel}'  multiple. 

Area  of  thickening  ahead  of  ulceration. 

Ulceration  advancing  from  a  central 
focus. 

Border  usually  raised  and  everted,  regu- 
lar in  outline. 

Often  assumes  fungoid  type. 

Base  may  be  deeply  excavated. 

Usually  painful. 

Bleeds  easily. 

Never  tends  to  cicatrize. 

Most  rare  in  the  young. 
Discharge  is  very  offensive. 
Lymphatic  involvement  nearly  always. 


Tuberculosis  (Lupus) 

Irritation  plays  no  figure.  Preceded  usu- 
ally by  nodules. 

Diathesis  evident.  Coincident  evidences 
of  tuberculous  disease  elsewhere. 

Often  multiple. 

Extension  of  ulceration  not  preceded  by 
thickening. 

Yarious  foci,  which  may  coalesce. 

Border  abrupt,  eaten,  irregular,  thick- 
ened, firm,  often  inverted,  irregular 
in  outline. 

Never  fungoid. 

Base  nearly  level  with  surface. 

Seldom  painful. 

Seldom  bleeds. 

As  marginal  ulceration  proceeds  there  is 
often  cicatrization  at  center. 

Common  in  the  young. 

Discharge  rarely  offensive. 

Barely. 


CHAPTER   XXXy 

THE  SURGICAL  DISEASES 

INFLAMMATION'    AND    THE    PEOCESS    OF    EEPAIK — BACTEEIA — ^SDPPUEATION 

SEPTICAEMIA 

Inflammation,  from  inflammo,  "to  set  on  tire/'  is  a  disturbance  of  nutrition 
in  the  tissues  of  a  part  of  the  body  resulting  from  the  presence  of  certain  bacteria 
or  pathogenic  micro-organisms.  This  disturbance  of  nutrition  is  characterized  by 
hypercemia  more  or  less  prolonged,  by  the  emigration  of  leucocytes  through  the 
vessel  walls  (diapedesis) ,  the  transudation  of  plasma  and  lymph,  and  by  a  tend- 
ency to  general  cell  proliferation  in  the  area  involved.  The  grosser  symptoms  of 
inflammation  are  lieat,  redness,  swelling,  pain,  and  loss  of  function. 

While  it  is  claimed — and  it  seems  to  be  demonstrated — that  one  or  more  of 
these  symptoms  may  be  present  in  certain  aseptic  conditions  in  which  hyperajmia, 
diapedesis,  transudation,  and  cell  proliferation  occur  (as  in  the  experiment  of 
injecting  an  aseptic  corrosive  chemical  beneath  the  skin  of  a  healthy  animal),  so 
far  as  piractical  surgery  is  concerned  the  above  definition  is  accepted.^ 

While  the  phenomena  of  inflammation  are  in  general  common  to  all  the  tissues, 
there  are  some  variations  by  reason  of  structure,  as  in  bone,  which  is  only  slightly 
expansile,  and  in  cartilage  and  the  cornea,  in  which  no  blood  vessels  exist. 

In  an  animal  body  in  which  the  processes  of  nutrition  are  approximately  nor- 
mal, the  tendency  in  the  tissues  which  are  the  seat  of  inflammation  or  local  dis- 
turbance of  nutrition  resulting  from  the  presence  of  bacteria  or  their  toxic  prod- 
ucts is  to  restore  as  near  as  possible  the  original  condition  of  these  tissues.     The 


Fig.  751. — Karyokinesis  of  the  fecundated  ovum  of  the  rabbit  (the  primary  embryonic  tissue)  arranged  in 
three  layers — the  ectoderm,  mesoderm,  and  entoderm.  At  pr.  the  ectoderm  and  mesoderm  have 
fused  together.     (Kolliker  and  Quain.) 

success  of  this  eilort  at  repair  must  depend  not  only  upon  the  condition  of  nutrition 
which  prevails  at  the  moment,  but  in  large  measure  upon  the  quality  and  quantity 
of  the  toxic  material  and  the  violence  to  the  tissues  immediately  involved. 

In  modern  aseptic  or  antiseptic  practice  the  conditions  in  the  process  of  repair 
are  so  nearly  physiological,  that  in  order  to  comprehend  these  conditions  the  stu- 
dent must  bear  in  mind  the  normal  development  of  the  tissues. 

'  In  vascular  tumors  (angeiomata)  there  is  a  condition  of  hyperaemia,  with  redness  without 
inflammation;  blushing  associated  with  certain  emotions  produces  localized  hyperjemia  with  red- 
ness and  is  a  physiological  process.  Active  hyperaemia  occurs  sometimes  after  injury  of  a  sympa- 
thetic nerve  and  this  may  be  accompanied  by  redness  and  swelling  without  inflammation.  Passive 
hyperaemia  due  to  interference  with  the  return  of  the  blood  through  the  veins  or  the  flow  of  lymph 
through  their  channels  causes  oedema  or  swelling  which  is  non-inflammatory.  In  the  hepatic 
vein  under  strict  physiological  conditions  the  blood  is  heated,  at  times  to  far  above  the  normal 
temperature.  Finally,  pain  is  not  infrequently  felt  as  in  neuralgia  where  no  other  symptoms  of 
inflammation  are  present. 

721 


722 


THE   SURGICAL   DISEASES 


The  fecundated  ovnm  of  the  parent  is  a  typical  cell,  which,  by  the  process  of 
primary   division   of   the   nucleus    (karyokinesis  ^)    indefinitely  repeated,   develops 
myriads  of  protoplasmic  cells  which  compose  the  primary  embryonic  tissue,   the 
blastoderm.      These    cells    arrange   themselves   in   three 
j_i'>n-,     'V  '^  groups  or  layers — the  outer,  or  ectoderm,  the  mesoderm, 

and  the  entoderm.  The  ectoderm,  by  continuous  pro- 
liferation, is  develoiDed  into  the  epithelia  of  the  skin, 
buccal  cavity,  the  ejDithelia  of  the  organs  of  sense,  of  the 
ventricles  of  the  brain,  the  canal  of  the  spinal  cord,  and 
forms  the  nervous  tissues.  The  entoderm,  excepting 
the  buccal  cavity,  forms  the  epithelia  of  the  alimentary 
canal  and  the  glands  in  connection  with  it.  The  meso- 
derm forms  the  renal  epithelia  and  the  epithelia  of 
the  vessels  and  serous  surfaces,  and  all  connective 
tissue,  cartilage,  bone,  muscle,  tendon,  ligament,  etc. 
■  (Quain). 
In  the  normal  processes  of  waste  and  repair,  as  epithelia  or  connective-tissue 
cells  are  worn  out  and  disappear,  new  cells  are  proliferated  by  the  parent  stock  to 
replace  them.  Epithelial  cells  by  karyokinesis  reproduce  their  kind,  and  in  like 
manner  the  connective-tissue  group  reproduce  connective  tissue.  In  simple  inflam- 
mation from  the  embryonic  tissue  which  is  the  common  product  of  the  proliferation 
of  all  the  fixed  or  resident  cells  in  the  area  involved,  the  destroyed  cells  are  re- 
placed by  new  cells  by  proliferation  of  their  parent  stock,  just  as  a  grain  of  wheat 
produces  wheat. 

The   ordinary   phenomena   of   inflammation   following   an   injury    are   as   fol- 
lows:   There   is   a    spasmodic    contraction    of   the   terminal    arterioles,   the    eapil- 


FiG.  751a. — Three  cells  from 
the  early  embryo  of  the  eat 
(highly  magnified).  6,  pro- 
toplasm; c,  nucleus  with 
nucleolus;  the  lower  one  a 
double  nucleated  cell. 
(After  Sharpey  and  Quain.) 


Fig.  7516.— Inflamed  mescnterv  of  a  frog.    T,  vein ;  .4 ,  small  Fig.  751c.— Diapedesis  or  emigration 

artery  and  capillaries.     The  red  corpuscles  are  seen  in  of   leucocytes  through  the  walls  ot 

the  center  of  the  current ;  the  white  blood-corpuscles  a  venule,     a,  incomplete,  6,    com- 

creep  along  their  inner  walls,  some  being  in  the  process  plete  emigration  (schematic),  (iill- 

of  emigration;  the  surrounding  tissues  contain  many  of  manns.) 
these  which  have  already  emigrated  from  the  vessels. 
(Tillmanns.) 

laries,  and  venules  in  the  injured  area,  followed  almost  instantly  by  dilatation 
of  these  vessels  far  beyond  their  normal  caliber.  The  volume  of  blood  is  at 
once  greatly  increased  to  fill  the  enlarged  channels,  and  the  current  is  more 
rapid,  since  capillary  resistance  is  less.  After  the  lapse  of  about  one  hour 
the  current  begins  to  slacken,  and  gradually  becomes  slower  than  before  the 
I  From  xapi"»'j  nucleus,  and  x"'')''''i>  movement. 


THE   SURGICAL   DISEASES 


723 


injury.  This  slowing  of  the  current  is  not  due  to  recontraction  of  the  vessels, 
but  to  a  clogging  of  their  channels  with  the  corpuscular  elements  of  the  blood. 
The  red  blood-corpuscles  and  the  placpies  ^  floating  in  the  plasma  occupy  the  center 
of  the  vessels,  while  the  white  corpuscles  (leucocytes),  which  normally  exist  in  the 
blood  in  the  proportion  of  from  1  to  1000  to  1  to  250  of  the  red  corpuscles,  are 


Fig.  751d. — A  white  corpuscle  or  leucocj-te  of  the  newt's  blood  with  three  nuclei,    a — e,  successive  forms 
assumed  at  intervals  of  a  few  minutes.     (After  Klein  and  Quain.) 

largely  increased  and  are  seen  to  adhere  to  the  vessel  walls  (Fig.  751&).  Since  the 
force  of  the  current  is  greatest  in  the  arterioles  and  least  in  the  venules  (which  have 
the  capillaries  between  them  and  the  heart  to  retard  the  circulation ) ,  the  leucocj^tes 
cannot  adhere  to  the  lining  membrane  of  the  arterioles ;  a  considerable  number  are 
seen  attached  to  the  capillaries,  while  the  venules  are  practically  choked  with  them, 
and  it  is  through  the  walls  of  the  venules  that  they  emigrate  (diapedesis,  BiaTr/jSav, 
to  ooze  through)  and  wander  into  the  intervascular  spaces  (Figs.  751&,  751c). 
Some  few  pass  through  the  capillaries,  but  none  have  been  observed  to  escape 
through  the  walls  of  the  arterioles.  The  leucocyte,  which  has  the  power  of  chang- 
ing its  form  (Fig.  Tolc).  pushes  through  the  line  of  union  of  the  flat  epithelium 
which  composes  the  wall  of  the  venule,  displacing  the  cement  substance,  and  finally 
emerging  'at  the  outer  side  of  the  vessel,  which  by  its  elasticity  at  once  closes  the 
aperture  of"  escape.  Coincident  with  the  clogging  of  the  venules  and  the  emigra- 
tion of  the  leucocytes,  by  reason  of  the  force  of  the  heart's  action,  the  plasma 
oozes  through  the  walls  of  the  blood  vessels,  producing  active  oedema,  and  a  little 
later  pressure  on  the  lymphatic  vessels  by  the  mass  of  newly  formed  cells  causes 
a  transudation  of  lymph — passive  osdema-^which,  mingling  with  the  escaped  plas- 
ma,  coagulates  outside  the  vessels.     In  some  instances  red  blood-corpuscles  and 


Fig.  7ole. — ^White  corpuscles  or  leucocytes  treated  with  water  and  with  acetic  acid.  1,  first  effect  of  the 
action  of  water  upon  a  white  blood-corpuscle;  2,  3,  white  corpuscles  treated  with  dilute  acetic 
acid:  n,  nucleus. 


plaques  may  also  escape  m  the  wake  of  the  emigrating  leucocytes  without  vascular 
rupture  and  produce  slight  discoloration  due  to  the  decomposition  of  hcematin,  the 
coloring  matter  of  the  red  disk.  Ecchymosis,  however,  is  usually  caused  by  ruptiire 
of  the  vessels,  with  free  extravasation,  and  the  formation  of  blood  clot  which  is 
invaded  by  and  probably  serves  as  food  for  the  proliferating  cells.  The  appearance 
of  the  escaped  leucocytes  in  the  tissues  is  marked  by  a  sudden  activity  in  the  vari- 
ous protoplasmic  elements  of  the  area  involved.  Every  normal  cell  in  the  zone  of 
irritation  takes  part  in  this  activity-  of  i^roliferation ;  but  since  the  connective-tissue 
cells  largely  predominate,  they  have  attracted  the  greatest  attention  of  observers 
and  furnish  as  well  the  greater  portion  of  the  embryonic  tissue.  The  protoplasm 
of  the  fixed  or  resident  cell  increases  in  size,  and  the  nucleus  undergoes  remarkable 
changes  (Fig.  75.3).  The  connective-tissue  cell  (Fig.  752)  consists  of  a  minute 
particle  of  protoplasm  in  the  center  of  which  is  a  nucleus.  The  nucleus  is  made 
up  of  a  network  of  nucleoli  and  threadlike  bodies  which  are  readily  stained  and 

1  The  plaques  or  "third  corpuscles"  of  the  blood  measure  from  1.3  to  3.5  micromillimeters  in 
diameter,  and  are  supposed  to  be  embryonic  red  blood-corpuscles.  They  consist  of  a  colorless  pro- 
toplasm, and  are  present  in  the  proportion  of  about  1  to  20  of  the  red  disks.  A  micron,  or  micro- 
millimeter,  is  isUo  of  an  inch.     The  Greek  character  /i  will  be  used  to  denote  a  micromillimeter. 


724 


THE   SURGICAL   DISEASES 


has  an  investing  membrane  of  its  own.  In  tlie  normal  condition  of  the  tissues  the 
fixed  cell  is  somewhat  flattened,  but  when  excited  to  proliferation  it  rajDidly  swells 
and  the  threads  in  the  nucleus  form  a  thicker  network,  soon  followed  by  an  hour- 
glass contraction  of  these  thickened  threads^   (karyomitosis),  near  the  center  of 


Fig.  752. Two  connective-tissue  corpuscles  from  the  subcutaneous  connective  tissue,  highly  magnified. 

The' dark  streak  below  I,  in  the  right-hand  corpuscle,  is  a  lamella  which  happens  to  be  projecting 
toward  the  observer,  and  is  seen  in  optical  section.     (After  Sharpey  and  Quain.) 

the  nucleus,  where  it  rapidly  divides  in  two,  the  thin  capsular  membrane  closing 
in  and  surrounding  each  new,  as  it  did  the  parent  nucleus  (Fig.  753).  The  main 
body  of  the  cell  may  now  divide  and  form  two  new  cells,  each  with  a  single  nucleus, 
.or  the  protoplasm  may  simply  enlarge  without  division,  the  nuclei  dividing  indefi- 
nitely within  the  cell.    In  this  way  the  poljTiucleated  or  '"'  giant  cells  "  are  formed. 


Fig.  753. — Karj'okinesis  in  the  cells  of  salamander  lari^a.  a,  cell  in  rest,  showing  parts  of  the  nuclear  net- 
work colored  black ;  tlie  remaining  portion  of  the  nucleus  is  the  nuclear  matrix ;  c,  nucleus  transformed 
into  closely  contorted  filaments;  /,  filaments  converging  toward  tlie  center  with  commencing  separa- 
tion into  an  upper  and  a  lower  portion;  k,  separation  more  advanced;  m,  a  further  step  in  the  proc- 
ess in  wliich  the  perinuclear  protoplasm  is  taking  part;  q,  two  cells,  the  product  of  karyokinesis,  the 
nuclear  network  again  assuming  the  cell  in  repose.      (After  Flemming  and  Quain.) 

It  is  now  held  that  all  cell  proliferation  takes  place  by  this  process  of  Mryohi- 
nesis,  or  primary  division  in  the  nucleus.  The  dilatation  of  the  blood  vessels,  with 
the  increased  supply  in  the  part,  the  escape  of  leucocytes,  plasma,  and  lymph,  and 
the  enormous  cell  proliferation,  cause  the  heat,  redness,  swelling,  and  pain  of 
inflammation,  together  with  the  loss  of  function  in  the  part,  as  well  as  a  partial 
or  comj)lete  stoppage  {stasis)  of  the  circidation  in  the  inflamed  area.  Stasis  is 
always  more  pronounced  at  the  center  of  the  disturbed  zone,  and  here  the  discol- 
oration is  deeper,  gradually  diminishing  toward  the  periphery.  The  sudden  con- 
traction and  immediate  dilatation  of  the  vessels  is  due  to  a  momentary  irritation 
of  the  vasomotor  nerves  and  the  paralysis  which  follows  their  injury.  It  is  diffi- 
cult to  explain  just  why  the  leucocytes  appear  in  such  large  numbers  at  the  seat 
of  inflammation.  It  is  claimed  that  they  are  attracted  there  by  some  chemical 
change  in  the  parts  involved,  and  this  is  termed  chemiotaxis."  In  all  probability 
their  chief  function  is  the  protection  of  the  injured  tissues  from  bacterial  invasion. 
That  they  are  pihagocytes  has  been  clearly  demonstrated.  Under  conditions  of 
mild  infection  in  tissues  where  the  resistance  is  near  the  normal,  the  process  of 
repair  begins  within  a  few  hours  after  the  injury.  The  phenomena  of  regeneration 
are  practically  identical  in  all  vascular  soft  tissues.     In  bone,  by  reason  of  the 

■  Karyomitosis,  from  x'V""'i  nucleus,  and  /iitos,  thread.  This  term  is  applied  to  the  increased 
size  and  changes  in  the  threadlike  contents  of  the  nucleus. 

-  The  property  living  cells  exhibit,  with  reference  to  non-living  organic  material,  by  virtue  of 
which  they  approach  or  recede  from  certain  substances.  In  positive  chemiotaxis  the  cell  ap- 
proaches, in  -negative  it  is  repelled  (Sternberg). 


THE   SURGICAL   DISEASES 


725 


dense  structure  ■which  surrounds  the  vessels  and  medulla,  and  in  the  two  non- 
vascular structures,  the  cornea  and  cartilage,  the  process  differs  somewhat  and  will 
be  specially  studied.  When  the  infection  is  virulent  or  when  the  tissues  are  of 
low  resistance  the  destruction  is  much  greater,  the  process  of  repair  is  slower,  and 


Fig.  754.— (.\fter  Paget.) 


Fig.  755.— (After  Paget.) 


regeneration  is  alwaj's  imperfect.  Chemical  and  mechanical  destruction  of  the 
tissues  is  alwaj"S  followed  by  the  formation  of  a  fibrillated  connective  tissue,  pro- 
ducing a  scar  or  cicatrix. 

The  most  important  step  in  the  regeneration  of  injured  tissue  is  the  distribution 
of  blood  and  nutrition  by  the  new  formation  of  vessels.  From  the  stumps  of  the 
divided  or  occluded  capillaries,  buds  (Fig.  756)  of  protoplasm,  springing  from 
the  new  cells  of  the  proliferating  endothelia,  are  projected  into  the  mass  of  em- 


FiG.  756. — Development  of  blood  vessels  bv  budding;  different  forms  of  buds,  a,  h,  c,  first  stages;  d,  f,g, 
simple  and  branching  solid  buds;  c.  vascular  bud  which  is  being  made  hollow  and  which  already 
contains  blood  corpuscles.     (After  Tillmarms.) 


726 


THE   SURGICAL   DISEASES 


bryonie  cells.  Some  of  these  meet  and  fuse  with  similar  buds  projecting  from 
opposing  surfaces  of  the  inflamed  area,  or  at  times  two  buds  from  the  same  surface 
unite  to  form  a  capillary  loop  (Fig.  755).  Some  of  these  embryonic  vascular  buds 
beo-in  as  tubules,  communicating  with  the  vessels  (e  Fig.  756),  while  others  are 
more  solid  prolongations  of  protoplasm  not  yet  canalized  {d  Fig.  756).  According 
to  Eanvier,  the  centers  of  these  undergo  liquefaction,  and  thus  becoming  canulated, 
they  ultimately  communicate  at  their  extremities  and  become  continuous  with  the 
vessels  from  which  they  spring.  The  cells  of  the  embryonic  tissue  immediately 
in  contact  with  the  new"  canals  aid  in  forming  the  walls  of  the  newly  made  vessels. 
When  hsemorrhage  has  occurred,  the  coagulum  is  rapidly  infiltrated  with  the  new 
cells  and  disappears  after  a  variable  time,  either  undergoing  granular  metamor- 
phosis or  is  taken  up  as  nourislunent  by  the  proliferating  cells.  Many  of  the 
capillaries  and  vessels  disappear  as  the  result  of  the  contraction  which  takes  place 
in  the  final  stage  of  inflammation.     This  formation  of  connective  tissue  (Fig.  757) 


Fig.  757. — Steps  in  the  fibrillation  of  connective-tissue  cells.      (After  Paget.) 

in  inflammation  is  at  times  so  extensive  that  occlusion  of  the  newly  formed  capil- 
laries is  often  complete,  giving  the.  j^eculiar  bleached  appearance  to  cicatricial 
tissue. 

In  the  sMn  the  repair  in  the  deeper  layers  of  the  cuticle  is  carried  on  by  the 
proliferating  prickle  cells  and  the  elongated  and  granular  cells  of  Langerhans, 
while  in  the  corium  the  embryonic  tissue  springing  from  the  fixed  connective- 
tissue  cells  develops  into  a  new  connective  tissue. 

In  adipose  tissue  the  fat  vesicles,  when  ruptured,  allow  the  escape  of  their  con- 
tents, which  disappears  by  granular  metamorphosis.  The  nucleus  of  the  capsule 
enters  into  the  general  cell  proliferation,  the  capsule  itself  being  originally  a  con- 
nective-tissue cell.  As  the  inflammatory  jKocess  subsides,  fat  droplets  again  appear 
in  certain  of  the  new  embryonic  cells  which  are  gradually  distended  and  form 
new  fat  vesicles   (Fig.   758). 

In  the  regeneration  of  muscle  the  process  is  somewhat  analogous  to  the  budding 
in  new  forming  capillaries.  From  the  ends  of  the  muscular  fibers,  which  are 
infiltrated  with  embryonic  cells  (to  the  formation  of  which  the  muscle  cells  or 
sarcoblasts  and  the  connective-tissue  cells  of  the  perimysium  contribute),  proto- 
plasmic swellings  or  buds,  which  are  rich  in  nuclei,  are  projected.  By  division 
of  the  nuclei  (practically  analogous  to  the  formation  of  muscle  plates  from  the 
mesoderm  in  the  embryo)  the  new  fiber  is  constructed,  meeting  and  becoming 
continuous  with  the  buds  from  the  opposing  surface.  These  formative  cells  arrange 
themselves  in  elongated  or  fusiform  shape,  in  which,  later  on,  fine  longitudinal 
striffi  are  seen.  The  transverse  striae  appear  about  the  twenty-first  day.  Muscle 
has  not  the  reproductive  power  of  other  tissvies,  and  when  the  injury  is  extensive, 
or  when  infection  or  suppuration  occurs,  the  lost  substance  is  replaced  by  fibril- 
lated,  connective,  or  cicatricial  tissue.  Even  when  new  fibers  are  produced,  their 
arrangement  is  not  so  symmetrical  as  in  the  normal  muscle. 

In  the  regeneration  of  tendon,  the  tendon  cells  and  the  connective-tissue  cells 
of  the  sheaths  are  the  agents  of  .proliferation  and  repair  in  inflammation  as  well 
as  after  surgical  or  accidental  division.  A  tendon  cell  is  a  fusiform  body  of 
protoplasm  containing  a  single  nucleus  in  which  are  several  nucleoli.     They  are 


THE   SURGICAL   DISEASES 


727 


arranged  in  rows  between  the  layers  of  fibers.     From  these  rows  tendon  buds  are 
projected,   wliich,  growing  longer,  become   tibrillated   and   arrange  themselves   in 
parallel  layers,  interlocking  with  the  growing  fibers 
or  buds  from  the  opposite  side. 

The  process  of  repair  in  inflammation  or  injury 
of  the  ligaments  is  practically  identical  with  that 
of  tendons,  and  need  not  be  separately  considered. 


Fig.  75S. — Deposition  of  fat  in  connective-tissue  cells  (adipose 
tissue).  /,  a  cell  with  a  few  isolated  fat  droplets  in  its  pro- 
toplasm; /',  a  cell  with  a  single  large  and  several  minute  drops; 
/",  fusion  of  two  large  drops;  g,  granular  cell,  not  yet  exhibit- 
ing any  fat  deposition;  c  t,  fat  connective-tissue  corpuscle; 
c,  c,  network  of  capillaries.      (.After  Sharpey  and  Quain.) 

In  nerves,  in  exceptional  cases,  the  repair  or  re- 
union takes  pilace  soon  after  extensive  injury,  with 
the  resumption  of  function.  As  a  rule,  however, 
restoration  of  function  takes  place  verj^  slowly.  The 
essential  element  of  conduction  is  the  axis  cylinder 
(Fig.  760).  In  some  nerves  and  at  points  in  many 
nerve  strands  the  outer  sheath  (nucleated  sheath  of 
Schwann)    and   the   medullary   sheath    (white    sub- 


G  759  —  lendon  of  mouse's  tail,  jhuwiiig  chains  of  cells  be- 
tween the  tendon  bundles;  175  diameters.  (After  Sharpey 
and  Quam.) 


stance  of  Schwann)  are  absent,  the  axis  cylinder  alone 
being  present.  This  axis  cylinder  is  the  greatly 
elongated  branch  of  a  central  nerve  cell  (Fig.  761). 
Wlien  destroyed,  that  portion  of  the  axis  cylinder 
on  the  peripheral  side  of  the  lesion  undergoes  de- 
structive metamorphosis,  and  the  function  of  the 
nerve  cannot  be  restored  until  the  central  end  of 
the  axial  band  buds  out  and  is  prolonged  through- 
out the  nerve  to  replace  the  cylinders  which  have  been  destro^^ed.  In  two  or 
three  weeks  after  the  lesion,  pale,  delicate  processes  are  seen  budding  out  from  the 


Fig.  760. — Portions  of  two  nerve 
fibers  stained  with  osmic  acid 
(from  a  3'oung  rabbit).  425 
diameters  Ji,  R,  nodes  of  Ran- 
vier,  with  axis  cylinder  passing 
through;  a,  primitive  sheath  of 
the  nerve;  c,  opposite  the  mid- 
dle of  the  segment  indicates  the 
nucleus  and  protoplasm  lying 
between  the  primitive  sheath 
and  the  medullary  sheath.  In 
A  the  nodes  are  wider,  and  the 
intersegmental  substance  more 
apparent  than  in  B.  (From  a 
drawing  by  Jlr.  J.  E.  Neale, 
after  Sharpej'  and  Quain.) 


728 


THE   SURGICAL   DISEASES 


axis  cj'linders  of  the  central  end  into  the  inflammatory  embryonic  tissue.  This 
process  of  budding  is  only  from  the  central  end  of  the  divided  nerve,  and  differs 
from  that  in  the  regeneration  of  capillaries,  tendons,  and  muscle,  in  which  the 

budding  is  from  both  the  iDroximal  and 
distal  ends.  (Biigner  claims  that  the  cells 
in  the  nucleated  sheath,  by  their  prolifera- 
tion, aid  in  the  restoration  of  the  cylinder, 
and  these  he  terms  neuroblasts.) 

The  slowness  with  which  nerve  trunks — 
the  seat  of  inflammation  or  injurj' — resume_ 
their  function  gives  weight  to  the  theory 
which  holds  that  the  projection  of  the  axial 
band  is  alone  from  the  central  and  parent 
nerve  cell.  As  much  as  twelve  months  have 
elapsed  after  careful,  aseptic  reunion  by  su- 
ture before  any  restoration  of  function  was 
observed  in  cases  in  which  complete  recov- 
ery resulted.  In  no  other  tissue  is  the  proc- 
ess of  repair  so  slow.  It  is  evident  that  care- 
ful apposition  without  unnecessary  tension  of 
the  sutures,  is  essential  to  successful  union. 

Periosteum  and  Bone. — Inflammation  of 
the  periosteum  causes  a  rapid  proliferation 
of  the  connective-tissue  cells  of  the  superflcial 
or  fibrillated  layers  of  this  structure,  and  of 
the  rich  supply  of  cells,  the  osteohlasts,  of 
the  layer  nearer  the  bone.  The  nerve,  blood 
and  lymph  vessels,  and  the  contiguous  bone 
must  of  necessity  take  part  in  the  process, 
and  when  at  the  seat  of  injury  the  fascia  or 
tendon  perforates  the  jDcriosteum  to  insert 
their  fibrilla3  deep  into  the  meshes  of  the  bone, 
they  also  contribute  something  to  the  produc- 
tion of  the  embryonic  tissue.  From  the  tenth 
to  the  fifteenth  day  after  the  injury  in  adults 
the  cells  which  have  remained  soft  begin  to 
be  infiltrated  with  calcareous  matter  (callus). 
From  the  twentieth  to  the  thirtieth  day,  under 
ordinary  conditions,  this  (provisional  callus) 
begins  to  be  absorbed  and  may  disappear  en- 
tirely by  the  end  of  sixty  days.  In  some  instances,  however,  it  in  part  remains  and 
is  transformed  permanently  into  bone  to  form  a  node  or  exostosis. 

A  t3rpical  non-infective  inflammation  of  bone  is  seen  in  simple  fracture,  the 
immediate  result  of  which  is  hfemorrhage  from  the  vessels  of  the  periosteum,  the 
compact  substance  and  medulla,  as  well  as  the  accidental  bleeding  from  the  con- 
tiguous soft  structures.  The  eoagulum  of  blood  and  lymph  covers  the  broken 
ends,  extends  a  short  distance  into  the  medullary  cavity  and  Haversian  canals, 
pressing  back  the  medulla  and  infiltrating  the  space  about  the  point  of  fracture. 
Into  this  clot  and  throughout  the  inflamed  area  the  emigrating  leucocytes  crowd, 
and  all  the  phenomena  of  cell  proliferation  wliich  their  presence  excites  takes 
place.  The  periosteal  osteoblasts  (Fig.  763),  the  bone  corpuscles  (Fig.  764)  which 
fill  the  lacunae,  the  "  giant  cells,"  or  myeloplaxes  of  Eobin  (very  large  masses  of 
protoplasm,  containing  usually  many  nuclei,  Fig.  765,  c),  or,  if  only  one,  this 
very  large,  and  the  common  and  very  much  smaller  mononuclear  cells  of  the 
medulla  (marrow  cells,  Fig.  765)  (found  not  only  in  the  central  medidla,  but 
also  in  the  Haversian  canals,  and  possessing  the  amceboid  properties  of  the  leuco- 
cytes), all  undergo  active  proliferation.  The  deeper  cells  of  the  periosteum  are 
at  first  most  active  and  throw  out  a  rich  mass  of  embryonic  tissue,  which  envelops 
and  surrounds  the  broken  ends  and  by  the  tenth  day  begins  to  be  infiltrated  with 


Fig.  761. — Ramified  nerve  cell  from  anterior 
cornu  of  spinal  cord  of  man.  a,  axis- 
cylinder  process;  b,  clump  of  pigment 
granules.  Above  the  cell  is  seen  part  of 
the  network  of  fibrils.  (After  Gerlach 
and  Quain.) 


THE   SURGICAL   DISEASES 


729 


lime  salts  to  form  a  callus.  From  the  fifteenth  to  the  twentieth  day  this 
(Fig.  767)  ensheathing  callus  is  complete,  and  holds  the  fragments  immovable  while 
the  process  of  ossification  is  going  on.     There  forms  also  about  the  same  time. 


Fig.  762. — Section  of  the  internal  saphenous  nen-e  (human),  made  after  being  stained  in  osmic  acid  and 
subsequentlj'  hardened  in  alcohol.  Drawn  as  seen  under  a  verjf  low  magnifj-ing  power,  ep,  epineuri- 
lun,  or  general  sheath  of  the  ner\-e,  consisting  of  connective-tissue  bundles  of  variable  size,  separated 
by  cleftUke  areolae,  which  appear  as  a  network  of  clear  lines,  with  here  and  there  fat  cells  (/  /)  and 
blood  vessels  (y)  ;  per,  funiculus  inclosed  in  its  lamellated  connective-tissue  sheath  (perineurium) ;  end, 
interior  of  funiculus,  showing  the  cut  ends  of  the  medullated  nerve  fibers,  which  are  imbedded  in  the 
connective  tissue  within  the  funiculus  (endoneurium).  The  fat  cells  and  the  ner\-e  fibers  are  darkly- 
stained  by  the  osmic  acid,  but  the  connective  tissue  of  the  nerve  is  only  shghtly  stained.  (After 
Sharpey  and  Quain.) 

in  the  young,  a  weaker  callus  from  the  central  medulla  cells  (pin  callus)  and 
from  the  marrow  cells  of  the  Haversian  canals — the  interosseous  callus.  In  older 
persons,  after  about  fifty  years,  it  is  held  that  no  central  or  pin  callus  forms.     It 


>^ 


Fig   763  —Periosteal  formation  of  bone  from  osteoblasts  FiG.  764.— A  bone  cell  isolated  and  higli- 

a;  b,  newlv  formed  bone:  c,  old  bone.      X  300.     (After  ly  magnified,     a,  proper  wall  of  the 

TiUmanns.)  lacuna,  shown  at  a  part  where  the 

corpuscle  has  shrunk  away  irom  it. 

(After  Joseph  and  Quain.) 

is  probable  that  in  all  cases  the  chief  factor  in  the  regeneration  of  bone  is  the 
bone  corpuscle  (Fig.  76J:).  It  is  well  kno-rni  that  the  periosteal  cells  (osteoblasts, 
Fio-.  76.3)  will  reproduce  bone  in  children  and  in  early  adult  life,  and  in  inflam- 
mation this  doubtless  assists  in  the  process,  but  the  bulk  of  their  product  usually 
disappears  by  absorption,  as  does  the  medullary  callus.  In  that  portion  of  the 
embryonic  tissue  which  springs  from  proliferating  bone  corpuscles  and  usually  is 


730 


THE   SURGICAL   DISEASES 


interposed  between  the  contiguous  surfaces  of  fractured  bone,  the  cells  are  trans- 
formed into  hyaline  substance,  in  which  cartilage  cells  appear.  As  in  the  original 
development  of  bone,  this  cartilage  is  soon  infiltrated  by  true  osteoblastic  tissue. 


Fig.  765. — Multinuclear  cells  from  bone  marrow,  highly  magnified,  a,  a  large  cell  the  nucleus  of  which 
appears  to  be  partly  divided  into  three  by  constriction ;  6,  a  cell  the  enlarged  nucleus  of  which  shows  an 
appearance  of  being  constricted  into  a  number  of  smaller  nuclei;  c,  a  so-called  giant  cell  (myeloplaxes) 
with  many  nuclei;  d,  a  smaller  cell  with  three  nuclei;  e-^,  other  cells  of  the  marrow.  (After  Sharpey 
and  Quain.) 

forming  the  osseous  lamellae.  In  addition  to  the  osteoblasts  there  appear  multi- 
nucleated cells  (myeloplaxes  of  Eobin  and  osteoclasts  of  Kolliker)  which  arrange 
themselves  in  rows  or  circles  and  cause  partial  absorption  of  the  osseous  substance, 
giving,  according  to  Sharpey,  the  festooned  appearance  tn  the  Haversian  spaces 
(Pig.  768).  Through  these  canals,  thus 
produced  jjy  absorption, 'the  new-formed 
vessels  make  their  way. 


Fig.   767. 

Fig.  766. — Fracture  healed  with  deformity  (callus  luxurians).      (After  Tillmanns.) 

Fig.  767. — Longitudinal  section  through  a  fracture  of  the  femur  three  weeks  old.  P,  periosteum;  K, 
bone;  M,  medulla.  Periosteal  callus  and  medullary  callus.  The  intermediary  callus  consisting  of 
periosteal  granulation  tissue,  which  is  o.ssified  only  in  some  places  and  is  partly  cartilaginous.  (After 
Tillmanns.) 

While  the  process  of  repair  in  bone,  as  Just  given,  is  closely  analogous  to  the 
formation  of  bone  from  the  blastoderm — namely,  primary  formation  of  cartilage 


THE   SURGICAL   DISEASES 


731 


and  the  replacement  of  this  by  osteogenic  tissue — this  does  not  alwaj's  occur.  In 
certain  bones  of  the  skeleton  (the  flat  bones  of  the  skull)  osteogenesis  is  not  pre-- 
ceded  by  cartilage  formation.  In  inflammation  with  loss  of  substance,  when  sup- 
puration has  occurred,  as  in  an  infected  compound  fracture,  embryonic  tissue  is 
directly  converted  into  bone. 

In  inflammation  of  the  cornea  (keratitis)  the  changes  are  very  much  the  same 
as  in  inflammation  of  the  tissues  which  possess  blood  vessels.    While  the  blood  does 


768. — Lacunar  absorption  of  bone  bv  osteoclasts  (O),  which  lie  in  Howship's  lacunce.       X250. 
(.\fter  Tillmanns.) 


not  circulate  in  the  cornea  proper,  there  are  certain  channels,  called  plasma  canals, 
through  which  plasma  and  lymph  convey  nutrition  from  the  blood  vessels  to  the 
tissues  of  the  cornea.     These  plasma  canals  undergo  a  dilatation  in  the  earlier 
stage  of  inflammation  analogous  to  that  of  the  blood  vessels  in  other  tissues,  and 
there  is  also  a  transudation  of  the  increased  fluid  between  the  lamella  of  which  the 
cornea  is  composed.     General  proliferation  ensues  in  the  corneal  corpuscles,  which 
is  preceded  by  emigration  of  leucocytes  from  the  blood  vessels  into  the  plasma 
canals.     The  presence  of  this  new  embryonic  tissue  causes  opacity  or  clouding  of 
the    cornea.      When   the    inflammatory   process    continues    for   a   sufficiently   long 
period  blood  vessels  shoot  out  from  the  corneal  margin,  into  the  cornea,  projecting 
their  capillary  buds  along  the  spaces  for- 
merly occupied  by  plasma  canals,  and  the  ^jsSB^. 
condition  of  pannus  is  established.     If  in-                         ''  ';;  '- 
fection  occurs,  suppuration  soon  takes  place            ,^ssr^     '     '  -   -•    .  .:  '■    > 
with  the  widespread  destruction  which  fol-         ^.dj'^"':           'vvrpjr?-          '■'■'■'.■' 
lows  the  presence  of  pus.    The  development      f ,-     ;  ,  •              ■■'*;»'.>:£.-         ,  •;■ 
of  blood  vessels  into  the  inflamed  area  is  a       '"--iiiUi-'  '^'^k 
conservative  process,  in  response  to  the  de-  ''m^ 
mand  for  increased  mitrition  and  for  re-  % 
moving   the   inflammatory   products   which 
undergo    granular    metamorphosis.      Ulti- 
mately these  new  blood  vessels  diminish  in 
size  and  gradually  disappear. 

In  cartilage,  inflammation  is  unlike  that  which  occurs  in  the  cornea,  for  in 
cartilage  there  are  no  vascular  spaces  whatever.  Nutritive  material  is  absorbed 
directly  by  the  cartilage  cells  and  hyaline  substance  from  the  blood  vessels  at  the 
point  of  contact  of  the  cartilage  with  the  bone.  In  the  early  stages  of  chondritis, 
the  cartilage  cells  are  swollen,  the  nuclei  enlarged,  the  intercellular  sul.)stance 
(hyaline)  becomes  liquefied,  or,  in  the  milder  form,  may  undergo  molecular  de- 
generation. If  the  inflammation  be  sufficiently  prolonged,  blood  vessels  may  be 
projected  into  the  area  involved.  Cartilage  is  a  tissue  of  such  low  vitalit}'  that  the 
process  of  repair  is  always  slow.  While  it  has  not  been  demonstrated,  it  is  in  all 
probability  true  that  new  cartilage  cells  are  produced  from  the  embryonic  tissue, 
the  product  of  the  original  cartilage  cells.  When  infection  by  bacterial  invasion 
occurs,  the  destruction'of  the  tissue  is  more  extensive  and  the  cartilage  cells  and 
hyaline  substance  are  generally  not  reproduced,  but  are  replaced  by  cicatricial 
tissue. 


Fig.  769. — ^Three  osteoclasts  from  absorption 
surfaces  of  growing  bone.  400  diameters. 
a,  with  thickened  striated  border.  (After 
Kolliker  and  Quain.) 


732 


THE   SURGICAL   DISEASES 


Inflammation  may  be  clinically  considered  as  moist  (suppurative)  or  dry 
(non-suppuratiye) . 

Suppurative  inflammation  may  be  considered  under  four  headings — i.  e.,  (1) 
that  which  affects  the  miicous  surfaces  (gonorrhoea,  conjunctivitis,  etc.),  (2)  the 
serous  surfaces  (peritonitis,  pleuritis,  etc.),  (3)  the  synovial  surfaces  (arthritis, 
thecitis),  and  (4)  that  which  affects  the  cutaneous  and  subcutaneous  tissues  (boils, 
abscesses,  osteomyelitis,  etc.). 

The  non-suppurative  inflammatory  lesions  may  be  subdivided  in  the  same 
manner:  Of  the  first,  diphtheria  is  a  type;  the  second,  peritonitis  and  pleuritis 
with  a  plastic  or  dry  (non-supportive)  exudate;  the  third,  a  similar  lesion 
of  the  joints;  and  fourth,  those  which  affect  the  skin  and  deeper  tissues  (ery- 
sipelas, anthrax,  glanders,  tuberculosis,  actinomycosis,  syphilis,  and  leprosy,  in 
none  of  which  is  pus  formed  without  the  presence  of  pyogenic  organisms — mixed 
infection).^ 

Pathogenic  Organisms. — Bacteria  (bacterium,  jBaKrqpwv ,  a  rod  or  staff)  is  a 
general  term  applied  to  all  these  minute  organisms,  and  the  science  which  treats 
of  them  is  bacteriology.  To  attempt  a  classification  of  these  organisms  in  the 
present  condition  of  science  would  be  unsatisfactory. 

Bacteria  have  been  named  chiefly  by  reason  of  their  shape.  Those  which  under 
the  microscope  appear  like  bits  of  broken  rods  are  called  bacilli  {bacillus,  a  little 


Fig.  770. — Different  varieties  of  cocci,  a,  smaller 
and  larger  cocci;  6,  diplococci;  c,  chain  coc- 
cus (streptococcus) ;  d,  e,  clusters  of  cocci  in 
the  form  of  a  bunch  of  grapes  (staphylo- 
cocci) ;  /,  sarcina  (packet  coccus) ;  g,  micro- 
coccus tetragonus.     (After  TiUmanns.) 


Fig.  771.  Fig.  772. 

Fig.  771. — Staphylococcus  pyogenes.  (Pure  cul- 
ture.)     (Modified  from  Landerer.) 

Fig.  772. — Streptococcus  pyogenes.  (Pure  cul- 
ture.)     (Modified  from  Landerer.) 


stick) .  The  very  longest  bacilli  are  sometimes  called  leptothrix  or  hairlike  ( Xeirro?, 
slender;  Opi$,  hair).  When  curvilinear  or  spiral  in  outline,  spirilla  {spirillum, 
a  curve).  When  round  or  near  so,  they  are  termed  cocci  {kokkv?,  a  berry  or 
kernel).  Some  of  these  divide  in  two  and  remain  attached  in  a  single  envelope, 
and  are  called  diplococci   (SiTrAoos,  double). 

Those  which  divide  in  two  directions,  forming  fours  which  adhere  together 
in  a  single  plane  in  the  same  gelatinous  envelope,  are  called  tetragonus  or  tetrads 
{riTpa,  four,  and ywvia,  angle),  a  four-angled  or  four-cornered  arrangement. 

When  they  divide  into  spherical  bodies,  which  at  times  cluster  together  by 
surface  agglutination,  they  are  called  staphylococci  {oTa^vXr],  a,  bunch  of  grapes). 

When  they  proliferate  in  one  direction  indefinitely,  like  the  links  of  a  chain, 
and  remain  joined  together,  they  are  called  streptococci  (o-TpeTrros,  a  chain). 

Adhering  in  groups  or  blocks,  zobgloea  {^Zov,  animal,  and  yAoios,  a  glutinous 
substance). 

Arranged  in  cubes,  they  are  sarcina  {sarcire,  to  arrange  in  order,  as  a  package 
or  bale). 

While  bacteria  are  chiefly  of  vegetable  origin,  consisting,  when  fully  developed, 
of  an  element  of  protoplasm,  containing  albuminous  matter,  fats,  salts,  and  water, 
and  enveloped  in  a  shell  of  cellulose,  recent  investigators  have  described  a  form, 

'  Certain  lesions  of  the  skin  due  to  the  lodgment  of  micro-organisms  and  parasites  in  the  hair 
follicles  or  upon  or  in  the  substance  of  the  integument  may  also  be  classed  as  non-suppurative 
lesions.     As  they  belong  to  the  domain  of  dermatology  they  are  not  considered  in  this  work. 


THE   SURGICAL   DISEASES 


733 


the  mycetozoa  (/;idk»/s,  fungus),  which  seems  to  belong  half-way  between  the  vege- 
table and  animal  kingdoms,  and  the  protozoa  (irpSTos,  first  or  beginning)  (ani- 
mal), which  are  considered  the  very  lowest  form  of  animal  life. 

Bacteria  reproduce  their  kind  in  two  ways:  by  division  (fission)  and  by  spore 
formation   ( sporulation ) . 

In  fission  the  parent  germ  usuallj''  becomes  elongated,  and  near  its  center  a 
pale  line  may  be  observed  in  a  direction  transverse  to  the  long  axis  of  the  germ. 
This  line  becomes  clearer  and  clearer  until  it  disappears  entirely,  and  the  two 
products  are  separated  into  independent  organisms. 

In  sporulation  the  protoplasm  of  the  germ  seems  to  condense  and  harden  and 
inclose  usually  a  single  spore.  On  account  of  the  thickening  of  the  capsule,  the 
spore  is  able  to  resist  destruction  to  a  greater  degree  than  the  parent  organism. 

Many  bacteria  are  capable  of  motion  while  a  large  group  are  non-motile.  Those 
that  are  non-motile  (certain  of  the  cocci)  are  at  times  seen  to  sway  en  masse. 
This  molecular  motion  is  also  called  the  "  Brownian  "  movement.  Quite  recently 
Ali-Cohen,  in  two  different  micrococci,  has  demonstrated  flagella  with  motion. 
By  a  recent  method  of  staining,  Loeffler  demonstrated  flagella — long  hairlike  fins 
— on  many  important  pathogenic  bacteria.  These  may  be  seen  at  one  or  both  ends, 
and  in  some  types,  as  the  typhoid  bacillus,  they  grow  out  in  all  directions.  These 
flagella  are  often  very  long  and  have  a  wavy  motion  (Fig.  775). 

Certain  forms  of  bacteria  can  live  without  oxygen;  they  are  called  anaerobic. 
The  greater  number  require  oxygen  and  are  termed  aerohic,  while  others  (com- 
parable to  the  amphibious  animals)  can  live  with  or  without  oxygen.  Those  which 
thrive  best  in  a  medium  containing  oxygen,  yet  can  exist,  however  stunted,  when 

this  gas  is  absent,  are  termed  faculta- 
®„o_  *ooOf5  o       ©0  ^^'^^'    (^^^'oiic    bacteria.       All    bacteria 

"  develop  best  in  alkaline  media.     The 

rapidity  of  their  proliferation  is  re- 
markable. Under  favorable  conditions 
a  single  organism  will,  within  twenty- 
four  hours,  by  dividing  and  redividing 
every  hour,  produce  more  than  sixteen 
million  of  its  kind,  and  they  have  been 
known  to  undergo  fission  in  so  short 
a  time  as  twenty  minutes.     The  pres- 


-Penicillium.  glaucum. 
(Tillmanns.) 


G,  774. — Yeast  fungus.  Saccharomj'ces  cere- 
visite.  Vacuoles  are  present  in  some  of  the 
larger  cells. 


ence  of  moisture  is  always  required  for  their  development,  and,  as  a  rule,  they 
develop  best  where  light  is  excluded. 

Certain  of  these  micro-organisms  form  coloring  matter  and  are  classed  as 
chromogenic  bacteria.  Others  produce  rapid  fermentation,  and  are  called  zijmo- 
genic. 

Bacteria  which  exist  outside  of  the  living  body  in  putrefying  animal  or  vege- 
table matter  are  called  saprophytes,  while  those  which  dwell  in  the  living  tissues 
are  called  parasites.  Some  of  these  organisms,  ordinarily  saprophytes,  but  capable 
of  existing  within  the  living  body,  are  called  facultative  parasites. 

Bacteria  which  possess  "the  faculty  of  liquefying  the  tissues  with  which  they 
come  in  contact  produce  pus  and  are  called  pyogenic  lacteria. 

The  principal  pathogenic  bacteria  of  surgical  interest  are:  Staphylococcus 
pyogenes  aureus,  epidermidis  albus,  citreus,  fluorescens,  cereus,-  flavus ;  micrococcus 


734 


THE   SURGICAL   DISEASES 


pyogenes  tenuis,  gonococcus,  microeoeeiis  tetragonus,  micrococcus  lanceolatns; 
streptococcus  erysipelatis  (Fehleisen),  streptococcus  pyogenes;  bacillus  pyocyaneus 
and  pyofluorescens,  bacillus  ruber  and  fcetidus,  bacillus  coli  communis,  bacillus 
tetani,   antliracis,    syphilis,   tuberculosis,   mallei,   lepra?,   typhi   abdominalis,    diph- 

tlierisB.^ 

As  yet  little  is  known  concerning  the  mycetozoa  and  protozoa.  The  former, 
sometimes  called  myxomycetes,  are  not  distinctly  animal  or  plant,  but  seem  to  be 
nearer  to  the  amcehce,  the  lowest  form  of  animal  life,  than  to  bacteria,  the  most 
elementary  plants.  As  protozoa  are  classed  the  following:  Plasmodium  malarise, 
the  o-erm  of  moUuseum  contagiosum,  and  a  peculiar  amoebic  organism  found  in  the 
discharges   of   dysentery    (Tillmanns).     The   fungi   or   molds — viz.,   penicillium. 


Fig.  775.— Typhoid  bacilli 


3  fine  flagella.     (After  Tillmanns.) 


oidium,  monilia,  mucor,  aspergillus,  and  especially  actinomyces — are  at  times 
important.  Certain  skin  diseases,  such  as  favus,  pityriasis  versicolor,  tinea  ton- 
surans, etc.,  are  caused  by  growing  fungi.  The  fungus  of  thrush,  which  at- 
tacks mucous  surfaces,  has  been  found  in  multiple  abscesses  (metastases)  in  the 
brain.  Aspergillus  is  occasionally  met  with  in  the  cornea  and  external  auditory 
meatus.  Mucor  myeelia  has  also  been  observed  in  multiple  abscess  of  the  brain, 
lungs,  and  bowels.  Yeast  fungi  (blastomycetes.  Fig.  774)  are  rarely,  if  ever, 
of  special  interest,  excepting  in  gastric  fermentation,  where  they  play  an  impor- 
tant role. 

Of  the  various  micro-organisms  of  pus,  the  staphylococcus  pyogenes  aureus  is 
the  most  common,  being  the  chief  factor  in  suppuration  in  about  eighty  per  cent 
of  all  cases.  This  organism  measures  0.7  ix  in  diameter,  is  killed  at  the  boiling 
point— 100°  C.  (213°  F.)  =— and  in  laboratory  experiments  at  58°  C.  (136.4°  F._), 
but  will  resist  desiccation  for  ten  days.    It  is  aerobic  and  practically  universal  in 

'  Sternberg  gives  the  thermal  death  point  in  streaming  steam  of  the  more  important  organisms 
as  far  as  known  as  follows:  S.  p.  aureus,  58°  C.  =136.4°  F.;  citreus  and  albus,  62°  C.  =143.6°  F. ; 
m.  tetragonus,  58°  C.  =136.4°  F. ;  streptococcus  pyogenes,  54°  C.  =129.2°  F. ;  s.  lanceolatus,  56°  C. 
=  132.8°  F.;  b.  typhi,  56°  C.  =132.8°  F.;  anthrax,  .54°  C.  =129.2°  F.;  malleus,  55°  C.  =131°  F.; 
diphtheria,  60°  C.  =  140°  F. ;  gonococcus  and  hydrophobia,  each  60°  C.  =  140°  F. ;  tuberculosis,  70° 
C.  =158°  F.;  all  spores,  100°  C.  =212°  F. 

^  A  simple  rule  for  the  conversion  of  Centigrade  to  Ft^hrenheit,  and  vice  versa:  212°  F. — 32  X  5 
H-9=100°C.;  100°  G.X9-H5  + 32=212°  F. 

Example:  212°  F.  100°  C. 

32  9 


ISO 
5 
9^900 
100°  C. 


5)900 

180 

32 

212°  F. 


THE   SURGICAL   DISEASES  735 

distribution,  being  found  in  the  soil,  upon  clothing  and  hands,  esiDecially  beneath 
the  nails,  but  rarely  in  the  air. 

The  next  in  order  of  importance  is  the  staphylococcus  pyogenes  (epidermidis) 
albus,  which  from  the  researches  of  Welch,  of  Johns  Hopkins,  is  of  considerable 
surgical  importance.  According  to  this  careful  investigator,  it  should  be  consid- 
ered an  almost  constant  inhabitant  of  the  epidermis.  It  lives  deep  in  the  folli- 
cles of  the  skin,  and  is  usually  the  cause  of  stitch  abscess.  This  demonstrates  the 
necessity  of  careful  scrubbing  of  the  integument  in  the  operative  field,  and  the  dis- 
solution of  sebaceous  matter  by  the  use  of  ether  poured  upon  the  skin. 

The  staphylococcus  citreus,  iiuorescens,  cereus,  flavus,  and  the  micrococcus 
pyogenes  tenuis,  are  unimportant  varieties.  The  gonococcus  will  be  separately 
considered  in  the  article  on  Gonorrhcea. 

The  bacillus  pyocyaneus  gives  the  color  to  blue  pus;  the  bacillus  pyofluorescens 
is  found  in  green  pus,  and  consists  of  small  rods  with  slightly  rounded  ends,  two 
or  more  of  which  are  linked  together  and  possess  active  movement.  It  does  not 
sporulate. 

The  bacillus  ruber  (Ferchmin)  is  found  in  red  pus. 

The  bacillus  foetidus  is  a  rare  form,  found  in  abscesses  chiefly  of  the  perirectal 
region. 

The  bacillus  coli  communis  (3  /*  in  length  and  0.6  ft.  in  breadth)  is  of  great 
surgical  interest,  since  it  is  considered  the  chief  agent  in  pus  formation  in  all 
suppurative  processes  in  the  peritoneal  cavity,  hepatic  abscess,  suppurating  gall 
bladder,  and  appendicitis.  AVelch  has  found  it  in  jDure  cultures  in  fifteen  different 
inflammatory  conditions. 

The  streptococcus  jDyogenes  and  the  streptococcus  erysipelatis,  so  far  as  micro- 
scopical appearance  is  concerned,  cannot  be  differentiated.  The  former  appears 
in  chains  of  from  four  to  six  cocci,  or  at  times  a  dozen  or  more,  linked  together 
in  a  single  chain.  It  is  facultative  anaerobic,  non-motile,  and,  in  common  with 
all  cocci,  reproduces  itself  by  fission.  It  possesses  great  vitality  in  living  tissues. 
There  is  one  clinical  point  of  difference  which  is  of  interest  between  the  strepto- 
coccus pyogenes  and  the  staphylococcus  pyogenes  aureus.  This  latter  organism 
is  associated  with  acute  circumscribed  inflammatory  processes,  with  rapid  pus  for- 
mation (circumscribed  abscess),  while  the  streptococcus  tends  to  produce  a  spread- 
ing suppurative  jDroeess  or  a  diffuse  phlegmon  or  abscess.  The  different  behavior 
of  the  streptococcus  of  erysipelas  will  be  considered  in  the  chapter  on  Erysipelas. 

The  micrococcus  tetragonus,  discovered  by  Gaffky  in  1881,  in  the  pus  of  acute 
abscesses,  is  found  in  the  sputum  of  tuberculous  subjects  as  a  rule,  as  well  as  in 
the  saliva  of  a  certain  proportion  of  healthy  individuals.  It  is  1  ju,  in  its  longest 
diameter,  and  while  usually  grouped  in  fours  (as  its  name  implies)  and  inclosed 
in  a  jellylike  capsule,  it  is  occasionally  met  with  in  groups  of  two  and  three.  It 
is  aerobic  and  under  certain  conditions  will  produce  fatal  septicemia.  Experi- 
ments on  animals  show  at  times  wide  dissemination  of  the  organism  throughout 
the  body,  while  in  others,  local  points  of  inflammation  have  been  found. 

The  micrococcus  lanceolatus  was  discovered  by  Sternberg  in  1880  in  the  buccal 
cavity  and  saliva  of  otherwise  healthy  individuals  in  about  twenty  per  cent  of  all 
cases.  It  is  constant  in  the  brick-dust  sputum  of  fibrinous  pneumonia.  It  appears 
commonly  in  the  form  of  a  diplococcus,  although  it  may  be  in  chains  of  from  four 
to  six  links.  In  shape  it  is  not  unlike  the  unstriped  muscular  cell,  being  fusi- 
form, somewhat  sharper  at  one  end  than  the  other.  When  they  join  together  they 
adhere  by  their  broader  ends.  Fresh  preparations  from  the  blood  of  animals  and 
saliva,  examined  under  the  microscope,  show,  although  not  invariably,  a  capsule 
surrounding  these  linked  organisms.  When  injected  into  the  peritoneal  cavity 
or  veins  of  animals  a  rapidly  fatal  septicasmia  is  produced.  It  is  considered  the 
specific  germ  of  lobar  pneumonia,  and  has  also  been  foimd  and  is  believed  to  be  a 
factor  in  producing  cerebro-spinal  meningitis,  pleuritis,  arthritis,  otitis  media, 
endocarditis,  and  pericarditis. 

The  typhoid  bacillus  (Fig.  775)  has  been  found  in  pure  cidtures  in  the  pus 
of  osteomyelitis  of  the  ribs,  in  acute  otitis  media,  empyema,  localized  peritonitis, 
either  during  or  as  a  sequela  of  typhoid  fever.     It  is  oval  or  fusiform  in  shape. 


736  THE   SURGICAL   DISEASES 

with  stubby,  rounded  ends,  and  has  projecting  from  its  surface  in  all  directions 
very  fine  hairlike  flagella,  with  which  it  propels  itself  in  active  motion.  Stained 
by  Loeffler's  method  it  looks  not  unlike  a  cotton  seed  with  particles  of  the  lint 
still  adherent.  In  typhoid  fever  it  is  found  in  the  blood,  faces,  and  urine,  show- 
ing the  wisdom  of  the  thorough  sterilization  of  these  excreta.  After  death  the 
bacillus  is  found  widely'  disseminated  and  chiefly  crowded  in  the  spleen,  liver, 
kidneys,  and  lymphatics  connected  with  the  intestinal  canal.  In  animal  experi- 
ments Saronelli  observed  that  when  the  normal  resistance  was  impaired  by  inject- 
ing certain  other  organisms — as  the  bacillus  prodigiosus,  proteus  vulgaris,  or 
bacterium  coli  commune — fatal  typhoid  lesions  resulted  in  animals  in  which  he 
could  not  obtain  a  reaction  prior  to  the  preliminary  inoculations.  Similar  results 
were  obtained  by  placing  the  animals  where  they  were  compelled  to  breathe  foul 
air  for  from  five  to  thirty  days.  This  bacillus  may  be  destroyed  in  the  urine  and 
fseces  by  adding  five,  or  preferably  ten,  times  the  quantity  of  boiling  water. 

The  micrococcus  of  tetanus,  anthrax,  malignant  oedema,  syphilis,  tuberculosis, 

glanders,  leprosy,  and  diphtheria  will  be  considered  separately  with  those  diseases. 

The  fungus  of  thrush  and  the  mucor  mycelia  have  also  been  found  in  metastatic 

abscesses  of  the  brain,  lungs,  and  intestines,  and  are  entitled  to  be  considered  as 

possibly  pyogenic  organisms. 

Suppuration. — Pyogenic  bacteria  possess  the  property  of  dissolving  or  lique- 
fying the  tissues  with  which  they  come  in  contact,  especially  those  in  which  nutri- 
tion is  disturbed  by  injury.  The  embryonic  cells  of  the  inflammatory  process 
yield  rapidly  to  their  destructive  presence.  The  coagulated  exudate  of  lymph  and 
plasma  or  extravasated  blood  is  liquefied  into  pus  serum,  and  the  leucocytes,  some 
living  but  mostly  dead,  float  in  the  serum  thus  made,  and  with  other  cells  of  the 
embryonic  tissue  not  yet  disintegrated  form  the  cellular  elements  of  pus.  The 
connective  tissues  are  also  dissolved  and  appear  in  shreds  mixed  with  the  pus 
cells  and  serum.  This  c'ollection  of  pus  is  called  an  abscess.  AVhen  well  defined 
and  held  in  position  by  a  limiting  membrane  or  wall  it  is  a  circumscribed  abscess, 
and  when  without  a  barrier  it  infiltrates  the  tissues,  a  dijfuse  abscess;  a  rapid  and 
recent  collection  of  pus  is  an  acute,  a  collection  of  long 
'^^ituafAhsecS&^  standing  and  free  from  pyogenic  organisms  (tuberculous 
^"^^^  "'  -.«s-»r..,!i  fluid)  is  called  a  cold  abscess.  The  lining  membrane  or 
wall  of  a  circumscribed  abscess  is  a  new  formation  of  in- 
flammatory origin,  the  inner  surface  of  which  is  a  granula- 
tion tissue  studded  with  capillary  loops,  as  in  the  embryonic 
tissue  of  a  wound  undergoing  repair.  It  is  in  part  a  pyo- 
genic membrane  (Fig.  776),  since  it  furnishes  the  dead  and 
cast-off  embryonic  cells  which  float  in  the  pus  serum,  while 
the  leucocytes,  the  pus  cells  proper,  wander  in  from  the 
capillaries  as  well  as  from  the  extravascular  spaces.  The 
Fig.  776.— (After  Agnew.)  deeper  layers  of  this  wall  of  defense  against  further  in- 
vasion by  micro-organisms  is  composed  of  rank  after  rank 
of  connective  tissue  and  other  fixed  cells,  active  in  the  proliferation  of  a  common 
embryonic  tissue. 

A  chronic,  subacute,  or  cold  abscess  differs  from  the  preceding  in  the  slowness 
of  its  development  and  the  absence  of  those  symptoms  of  local  and  constitutional 
disturbance  which  characterize  the  acute  formation  of  pus.  It  occurs,  as  a  rule, 
in  diseases  of  the  bone  and  joints,  and  in  individuals  of  low  vitality  (diminished 
resistance),  and  is  most  frequently  seen  in  connection  with  caries  of  the  spine 
(Pott's  disease),  in  other  forms  of  tuberculous  ostitis,  and  in  tuberculous  lympho- 
mata.  Such  abscesses  are,  as  a  rule,  of  tuberculous  origin,  and  do  not  contain  true 
pus.  While  in  gross  appearance  the  contents  may  resemble  pus,  the  microscope 
shows  that  the  normal  elements  of  pus  are  not  present.  Under  such  conditions 
the  danger  of  general  infection  from  the  bacillus  of  tuberculosis  is  small.  The 
bacillus  tuberculosis  produces  a  subacute  inflammatory  process,  which  results  in 
a  rich  granulation  tissue,  the  base  of  which  is  composed  of  newly  formed  cells, 
the  embryonic  tissue  of  the  inflammatory  process,  which  hedges  in  the  tuberculous 
focus  and  tends  to  prevent  systemic  invasion.     The  tendency  of  these  products  of 


THE   SURGICAL   DISEASES  737 

the  tuberculous  process  is  to  undergo  rapid  degeneration,  due  in  part  to  the  toxic 
product  of  the  bacillus  (chemical  action)  as  well  as  by  anaemia,  both  local  and 
systemic.  As  a  result  of  this  retrograde  metamorphosis,  caseation  and  liquefac- 
tion of  caseous  material  occurs,  the  product  being  a  white  liquid  of  varying  con- 
sistence, resembling  but  not  being  pus. 

Under  favorable  conditions  these  collections  of  tuberculoiis  fluid  tend  to  alDSorp- 
tion.  In  the  majority  of  instances  the  wall  of  embryonic  cells-  offer  sufficient 
resistance  to  invasion  of  the  tuberculous  germs  into  the  general  system.  The 
liquid  is  absorbed  ultimately  and  carried  away  as  a  harmless  product,  and  the 
remaining  caseous  matter  undergoes  granular  metamorphosis  and  of  itself  ulti- 
mately disappears.  Such  pathological  processes  do  not  have  symptoms  in  any  way 
in  common  with  abscesses  proper,  which  are  the  seat  of  acute  inflammation  caused 
by  pyogenic  germs.  Pain  is  not  a  marked  symptom,  since  they  can  exist  for 
months  and  are  not  suspected  until  the  collection  of  this  milljy  fluid  is  sufficient 
to  attract  attention  by  pressure  upon  the  abdominal  viscera,  or  protrusion  due  to 
its  size. 

It  is  a  recognized  fact  that  these  tubercular  foci  can  become  infected  with 
pyogenic  micro-organisms  without  direct  communication  with  the  air.  Certainly, 
if  the  medulla  of  bone  can  become  infected  without  a  direct  or  external  communi- 
cation, it  is  Just  as  easy  to  infect  a  deep-seated  tuberculous  fluid  when  conditions 
for  infection  are  favorable,  the  germs  traveling  through  the  blood  and  being  depos- 
ited in  a  suitable  pabulum. 

The  treatment  of  the  two  classes  is  clearly  indicated.  The  simple  tuberculous 
focus,  under  ordinary  conditions,  when  located  in  the  epiphyses  of  the  long  bones 
or  in  the  vertebrse  or  in  deep  situations,  may  be  left  alone  to  undergo  absorption, 
taking  pains  by  careful  nourishment  and  hygienic  precautions  to  increase  the 
normal  resistance  of  the  tissues  and  prevent  general  infection.  On  the  other  hand, 
when  in  the  lymphatic  glands  or  in  superficial  locations  readily  accessible,  or  when 
a  tuberculous  accumulation  is  the  seat  of  a  mLxed  infection,  as  determined  by  the 
ordinary  symptoms  of  septic  infection,  local  and  general,  then  a  careful  aseptic 
invasion  and  removal  or  evacuation  is  indicated. 

Pus. — Pus  is  a  liquid  or  semiliquid  of  varying  color,  for,  while  usually  yellow- 
ish white,  it  may  possess  a  well-marked  hue  of  red,  blue,  orange,  or  green.  It 
consists  of  a  fluid  portion,  jms  serum;  cellular  elements,  to  be  described  as  pus 
cells;  various  micro-organisms;  at  times  red  disks,  crenated,  and  in  various  stages 
of  disintegration;  fat  globules,  fibrin,  and  shreds  of  necrotic  tissue  not  yet  lique- 
fied, and  crystals  of  cholesterin.  There  are  also  found  in  pus,  paraglobulin,  serum 
albumin,  myosin,  leucin,  tyrosin,  and  potassium  albuminate   (Fig.  777). 

Eecent  pus  is  usually  alkaline  in  reaction,  but  when  exposed  to  the  air  it  be- 
comes acid.  Moreover,  it  may  Ijo  without  odor,  but  when  accompanied  by  decom- 
position of  necrotic  tissue,  from  which  gases  are  evolved,  or  when  proceeding 
from  an  inflamed  area  contiguous  to  the  alimentary  canal,  it  is  often  extremely 
offensive. 

Surgical  (septic  or  bacterial)  pus  does  not  coagulate.  Pus  serum,  although 
furnished  from  the  vessels  of  the  inflamed  area,  is  prevented  from  coagulation  by 
the  liquefying  action  of  bacterial  peptone,  a  product  of  bacterial  ferment  and 
decomposition. 

Pus  cells  are  chiefly  white  blood-corpuscles,  which  by  chemical  attraction 
(chemiotaxis)  have  crowded  into  the  inflamed  area.  Treated  with  dilute  acetic 
acid,  they  seem  to  possess  two  or  three  nuclei,  rarely  a  single  nucleus. 

The  single  nucleated  cells,  found  in  large  numbers  ta  pus  and  classed  as  pus 
corpuscles,  are  cast-off  products  of  the  new  embryonic  tissue,  due  to  cell  prolifera- 
tion. In  recent  pus,  and  in  a  warm  medium,  some  of  the  corpuscles  are  capable 
of  amceboid  movement.  Their  number  varies  from  four  hundred  thousand  to  one 
million  six  hundred  thousand  in  one  cubic  millimeter. 

The  poisonous  products  of  bacteria,  if  separated  from  the  micro-organism  from 
which  they  are  derived,  produce  suppuration  or  toxic  symptoms  similar  to  those 
produced  by  the  bacteria,  but  the  poisonous  effect  is  only  transient,  since  the  parent 
bacteria  is  essential  to  maintain  prolonged  septic  infection. 


738 


THE   SURGICAL   DISEASES 


Certain  sterilized  cliemieal  substances,  as  well  as  sterilized  bacteria,  will,  when 
injected  into  the  tissues,  cause  inflammation  and  a  liquefaction  of  the  exuded 
plasma  and  connective  and  embryonic  tissues  with  which  they  cortie  in  contact, 
and  produce  a  creamy  liquid  which  very  closely  resembles  true  surgical  pus.     The 


Fig.  777. — (Modified  from   Thomas.)     a,  compound   granular  corpuscles;  b,  crystals  of   choleslerin; 
c,  pus  cells;  d,  same  after  addition  of  acetic  acid. 


inflammatory   process,  however,   is  mild,   and   systemic   infection  does  not  occur. 
Surgical  writers  have  termed  this  "  laboratory  pus.'"' 

Treatment. — In  the  treatment  of  inflammation  the  first  great  essential  is  rest, 
and  this  should  be  as  complete  as  possible.  If  necessary  to  assure  this,  some  form, 
of  fixation  apparatus  should  be  applied.  In  non-infective  inflammation,  as  a  rule, 
nothing  further  than  this  will  be  required  to  bring  about  absorption  of  the  excess 


r^G^i- 


Fig.  778. — Pus  from  an  acute  abscess,  showing 
pus  cells,  shreds  of  broken-down  connective 
tissue  and  micrococci.      (After  Landerer.) 


Fig.  779.— 

(Aft^ 


Bacilli  of  blue  pus. 
;r  Landerer.) 


of  embryonic  tissue  and  coagulated  exudates,  and  the  repair  or  regeneration  of  the 
tissues  which  have  been  injured.  As  far  as  local  applications  are  concerned,  as- 
a  rule,  patients  prefer  cold  to  heat.  The  neatest  way  to  apply  cold  is  by  the  rubber 
ice-bag,  which  can  be  laid  directly  upon  the  inflamed  part,  with  a  piece  of  lint 
or  thin  layer  of  cotton  batting  between  the  skin  and  the  ice-bag.  The  cold-water 
coil  (Fig.  780)  is  also  very  usefitl.  In  the  absence  of  these  preferable  methods, 
benefit  may  be  derived  by  applying  towels  dipped  in  cold  water,  partially  squeezed- 
out,  and  laid  directly  upon  the  inflamed  surface.  When  one  of  the  extremities  is 
the  seat  of  lesion,  the  painful  throbbing,  which  is  often  a  part  of  inflammation. 


THE   SURGICAL   DISEASES 


739 


may  in  good  part  be  relieved  by  elevation  of  the  limb.  For  the  upper  extremity 
the  Fluhrer  swing  (Fig.  781)  is  useful  for  this  purpose,  and  adds  to  the  patient's 
comfort.  A  very  important  feature  in  the  treatment  of  all  surgical  lesions  is  a 
careful  attention  to  the  condition  of  the  alimentary  canal.     It  is  of  great  impor- 


FiG.   780. — (Modified  from  Fischer.) 


tance  that  the  alimentary  canal  be  carefully  emptied,  and  kept  empty  to  prevent 
intestinal  toxjemia. 

In  suppurative  inflammation  more  urgent  measures  are  demanded.  It  is  diffi- 
cult to  deal  with  any  form  of  infective  inflammation  without  the  use  of  the  knife, 
even  in  its  early  stages,  and  the  sooner  the  knife  is  used  in  these  cases,  as  a  rule, 
the  better.  It  is  a  surgical  axiom  that  wherever  infection  has  occurred  and  pus 
is  forming,  the  sooner  an  incision  is  made  the  quicker  will  recovery  follow  and 
less  danger  ensue  to  the  life  and  comfort  of  the  patient  and  the  usefulness  of  the 
part  involved.  The  treatment  of  all  abrasions  or  deeper  wounds  should  be  strictly 
antiseptic  from  the  moment  a  wound  comes  under  consideration.  If  the  laity  were 
thoroughly  trained  in  the  simplicitv'  and  safety  of  the  sterilization  of  wounds,  not 
one  in  a  hundred  of  the  serious  accidents  of  infection  would  occur.    Patients  should 


740 


THE   SURGICAL   DISEASES 


be  instructed  to  keejD  on  hand  tablets  of  bichloride  of  mercurj^  with  directions  for 
making  a  simple  and  safe  solution  in  which  an}'  part  of  the  bod_y  may  be  immersed 
or  bathed;  and,  this  being  done,  to  dry  the  wound  off  with  a  clean  towel  that  has 
been  boiled,  press  the  edges  of  the  abrasion  together,  and  cover  the  exposed  surface 
with  a  layer  or  two  of  ordinary  collodion,  applied  with  a  brush  or  jjoured  on.  When, 
however,  a  wound  has  been  neglected  and  sepsis  is  established  in  the  earlier  stages, 
the  next  best  thing  is  to  cocainize  the  jjart  by  the  injection  of  from  one  to  ten 
minims  of  a  two-per-cent  solution  into  the  integument  about  the  wound,  taking 
pains  to  follow  the  directions  given  in  the  use  of  cocaine  in  the  chapter  on  local 
anaesthesia;  then  incise  in  the  safest  direction  the  focus  of  infection,  and  inject 
from  thirty  to  sixty  minims  of  a  1-3000  bichloride  solution  into  the  tissues,  making 
a  complete  circle  of  the  area  of  infection.  When  lymphangitis  is  established  and 
septic  inflammation  has  taken  place  along  the  lymphatic  channels  toward  the  center 
of  the  body,  at  the  first  indication  of  suppuration  in  the  glands  they  should  in 
like  manner  be  incised  so  that  the  current  of  septic  matter  coming  into  them  from 
below  may  be  poured  out  into  a  wound  where  sterilization  is  secured  by  antiseptic 
moist  dressing  and  infection  beyond  the  lymphatic  glands  prevented. 

In  a  condition  of  general  cellulitis  resulting  from  infection  it  is  imperative  to 
make  multiple  incisions,  not  only  to  relieve  tension  and  prevent  gangrene,  but  to 
give  free  escape  to  septic  matter  and  to  permit  sterilization  of  the  deeper  portion 


Fig.  781. — Fluhrer's  swinging  cradle  (Mt.  Sinai  Hospital). 

of  the  infected  tissues  and  secure  as  thorough  drainage  as  may  be  possible.  On 
general  surgical  principles,  all  incisions  should  be  made  parallel  with  the  axis  of 
the  body.  Any  variation  from  this  practice  should  be  made  for  the  purpose  of 
keeping  away  from  any  nerves  or  vessels  which  might  run  in  another  direction. 

The  recognition  of  an  acute  abscess  will  depend  upon  certain  symptoms  of  a 
local  as  well  as  a  constitutional  character.  The  sudden  rise  of  temperature,  pre- 
ceded by  a  chill  or  series  of  rigors,  are  symptoms  of  purulent  infection.  The  local 
signs  are  those  of  inflammation — heat,  pain,  redness,  and  swelling.  Fluctuation 
is  also  present  in  well-advanced  cases.  The  integument  and  subcutaneous  tissues 
about  an  abscess  are  often  oedematous  and  doughy.    The  positive  test  is,  however, 


THE   SUEGICAL   DISEASES  741 

by  aspiration.  A  hypodermic  syringe  (used  only  for  this  purpose)  Trith  a  large- 
sized  needle  (Fig.  782)  is  iavaluable.  The  needle  shoiild  be  held  over  a  flame 
or  boiled  Just  before  using.  It  is  best  to  employ  strict  antiseptic  precautions  ia 
aspiration  as  ia  other  surgical  procedures.     A  preliminary  injection  of  one  or  two 


Fig.  782. — Exploring-needle  and  syringe. 

minims  of  tTro-per-cent  cocaine  solution  -svith  the  finest  needle  -niU  prevent  pain. 
If  incision  is  determined  upon,  the  same  anaesthetic  may  be  employed. 

In  the  neck  or  in  any  vasctdar  region  it  is  best  to  dissect  carefully  down  to  or 
near  the  abscess  wall.  In  some  cases  it  is  safer  to  push  a  dressing  forceps  tightly 
closed  through  the  tissues  into  the  abscess,  then  separating  the  blades  and  stretching 
the  opening,  through  which,  after  irrigating  with  1-3000  bichloride  solution,  a 
drainage-tube  is  inserted. 

The  constitutional  symptoms  of  septic  infection  should  be  combated  by  careful 
attention  to  the  condition  of  the  alimentary  canal,  as  heretofore  described,  and  the 
prompt  and  persistent  efEort  by  careful  nourishment  (and  stimulation,  if  neces- 
sary), and  by  a  bountiful  supply  of  as  pure  air  as  can  be  obtained,  to  hold  the 
tissues  of  the  patient  as  nearly  as  possible  in  a  condition  of  normal  resistance. 
The  survival  of  the  patient  depends  upon  the  power  of  the  tissues  to  resist  de- 
struction from  the  invading  micro-organisms  until,  failing  to  find  a  suitable  pabu- 
lum for  their  rapid  proliferation,  they  perish.  In  suppttrative  cases,  after  incision 
a  warm,  moist  dressing  of  weak  bichloride  or  of  plain  sterilized  gauze  covered  in 
with  protective  or  oO.  silk  to  prevent  evaporation,  is  often  advisable.  In  exceptional 
instances  an  aseptic  poultice,  made  by  wetting  flaxseed  meal  or  any  other  substance 
in  warm  bichloride  solution  (1-.5000),  may  be  employed  with  benefit. 

Septiccemia. — Septicamia  {cnprriKO's  putrid,  oLija  blood),  or  blood  poisoning 
(with  or  without  metastases),  results  from  the  entrance  into  the  blood  channels 
of  either  an  infectious  organism  or  the  ptomaine  or  toxic  product  of  such  organ- 
ism, or  of  gaseous  emanations  from  the  decomposition  of  diseased  tissues  of  the 
body  or  of  ingested  material.  The  term  pycemia  was  formerly  used  to  imply  the 
entiance  into  the  blood  of  the  semisolid  products  of  suppitration,  while  septico- 
pycem  ia  is  now  proposed  by  some  writers  to  express  a  mixed  condition  of  septicemia 
and  pysemia.  It  seems  to  me,  however,  that  an  effort  should  be  made  to  simplify 
the  terms  used  in  pathology,  and  that  septiccemia  would  express  a  condition  of 
blood  poisoning  in  which  metastases  do  not  occur,  while  septiccemia  with  metastases 
would  express  all  that  is  contained  in  the  term  "pysemia.'"'  The  term  septico- 
pyemia is  entirely  unnecessary. 

Septicemia,  or  blood  poisoning,  may  be  caused  not  only  by  the  presence  of 
bacteria  in  the  tissues,  but  can  also  be  prodtieed  by  ptomaines,^  or  toxic  products 
derived  from  these  organisms  entirely  separated  from  the  bacteria  which  produced 
them.  TThen  septic  bacteria  are  present,  the  septicemia  is  sudden,  and  may  con- 
tinue indefinitely,  while  the  septicemia  restilting  from  the  toxic  products  alone 
is  temporary.  Septic  infection  takes  place  in  the  vast  majority  of  cases  from  an 
abrasion  or  wound  of  the  skin  or  m.ucous  membrane :  bacteria,  entering  here,  travel 
into  the  tissues,  hTuph  spaces,  and  blood  vessels,  and  in  severe  cases  are  rapidly 
disseminated  by  the  blood.     They  attack  by  preference  the  white  blood-corpuscles 

I  Various  basic  substances  containing  nitrogen  and  in  chemical  constitution  resembling  the 
vegetable  alkaloids  have  been  isolated  by  chemists  from  putrefying  material  and  from  cultures  of 
bacteria  concerned  In  putrefaction,  as  well  as  from  certain  pathogenic  organisms.  These  products 
are  called  ptomaines  (TrrafuL.  a  corpse).  In  contra-distinction  to  the  ptomaines  are  the  leucomaines 
{KevKdifia.  white  of  egg),  which  differ  from  the  foregoing  in  that  they  are  derived  from  tissue 
changes  in  the  body  fndependent  of  the  presence  of  bacteria.  Among  the  ptomaines  are  neuridin, 
cadaverin,  putresein.  saprin.  methylamine.  dimethylamine.  and  trimethylamine.  Also  neunn. 
derived  from  decomposirion  of  braiii  matter  and  putrefying  muscular  tissue:  cholin.fotmd  in  hogs' 
bile,  in  the  yolk  of  eggs,  etc.:  muscarin.  found  in  poisonous  mushrooms  and  putrefying  fish:  pep- 
totoxin,  tyrotoxiconrfyphotoxin,  from  cultures  of  typhoid  bacillus:  tetania,  from  tetanus-bacillus 
cultures. 


742 


THE   SURGICAL   DISEASES 


until  these  seem  to  be  mere  aggregations  of  bacteria.  The  red  blood-corpuscles 
later  become  disintegrated,  and  after  death  the  blood  is  dark  in  color  and  decom- 
poses rapidly.  Hffimorrhages  occur  in  the  gastro-intestinal  tract  and  various  or- 
gans; the  spleen  and  liver  are  enlarged  and  softer  than  normal;  the  kidnej's  are 
seriously  affected  and  seem,  from  the  shoals  of  micro-organisms  found  in  them, 
to  be  chiefly  depended  upon  for  the  elimination  of  the  bacteria.  Septicaemia  in 
severe  cases  is  introduced  by  high  and  continuous  fever,  with,  however,  varying 
temperature,  rapid  pulse,  great  discomfort,  and  a  feeling  of  prostration.  In  milder 
cases  fever  may  be  wanting.  In  some  instances  there  are  repeated  chills,  followed 
invariably  by  a  rapid  rise  of  temperature.  From  the  point  of  infection  the  progress 
of  invasion  is  marked  by  lymphangitis  and  at  times  by  pWehiiis,  a  condition  favor- 
able for  the  development  of  pyemia  and  inflammation  of  the  skin  and  subcutaneous 
connective  tissue.  The  lymph  glands  l)etween  the  wound  of  infection  and  the 
central  organs  become  enlarged  and  break  down  in  suppuration.  When  the  cellu- 
litis or  phlegmon  is  extensive,  gangrene  may  ensne  on  account  of  the  tension  of  the 
parts  involved  and  the  interference  with  the  circulation.  The  parts  are  swollen, 
and  often  extremely  painful. 

In  the  treatment  of  septictemia  it  is  of  vital  importance  to  regard  all  wounds 
as  capable  of  conveying  infection  to  the  tissiies ;  and  if  the  principles  of  prophylaxis 
just  given  in  the  treatment  of  infective  inflammation  were  carefully  carried  out, 
there  would  be  no  such  thing  as  septic  infection.  When  infection  has  taken  place, 
and  free  incision  been  made,  it  is  advisable,  after  making  the  incisions,  to  keep 
the  hand  or  part  involved  submerged  in  a  warm  solution  of  bichloride  of  mercury 
(1  to  2000  to  3000)  for  at  least  half  an  hour  after  the  incisions  are  made.  Beyond 
this  local  treatment  not  much  can  be  done  except  to  support  the  patient  in  every 
way  by  careful  nourishment  and  proper  stimulation.  When  the  lymphatic  glands 
become  engorged  and  are  about  to  suppurate,  they  should  be  incised  and  treated 
as  the  original  point  of  infection. 

Septicwmia  with  Metastases. — In  septicamia  with  metastases  (pj'semia)  the 
symptoms  just  given  as  characteristic  of  simple  septicaemia  are  exaggerated;  the 


Fig.  7S3. — Bacilli  of  septicEemia  in  a  vein  of  the  diaphragm,  taken  from  a  septiccemic  mouse.  White 
ijlood-corpuscles,  some  containing  bacilli  and  some  changed  into  masses  of  bacilli.  X  700.  (After 
Koch.) 

Tesistance  of  the  tissues  in  the  inflamed  area  seems  lessened ;  the  blood  vessels  are 
invaded  by  the  bacteria  (Fig.  783),  and,  as  a  result,  clots  or  thromhi  form  upon 
the  vessel  walls,  which,  under  the  disintegrating  action  of  the  micrococcus  of 
inflammation,  break  do-mi,  and  thus  purulent  fragments  are  swept  along  the  blood 
channels  to  the  heart,  from  whence  they  are  distributed  through  the  lungs  to  the 
various  organs  of  the  body.  They  form  emhoU,  or  arrested  clots,  chiefly  in  the 
capillaries  of  the  lungs,  and  each  embolus  may  form  a  metastatic  abscess.  From 
here  other  thrombi  are  developed,  and  these  are  swept  into  the  circulation  and 
■distributed  by  the  left  ventricle  to  the  entire  system.  If  the  point  of  infection  is 
in  the  area  of  the  portal  system  the  liver  is  apt  to  be  the  seat  of  metastatic  abscesses. 


THE   SURGICAL   DISEASES  743 

In  Mr.  Thomas  Br3'ant's  analysis  of  two  hundred  and  three  cases  at  Guy's  Hospital 
the  lungs  were  involved  in  one  hundred  and  eighty-seven,  and  in  seventy-eight  of 
these,  infarctions  occurred  in  no  other  organ.  The  fever  in  pysemia  is  usually 
preceded  by  a  chill,  and  this  is  apt  to  recur  with  more  or  less  frequency  during 
the  disease.  The  febrile  movement  does  not  follow  a  regular  course,  but  is  gen- 
erally intermittent.  After  a  high  temperature  there  is  a  sudden  fall,  often  coin- 
cident with  profuse  and  exhausting  sweats.  The  thermometer  not  infrequently 
within  a  period  of  twelve  hours  will  vary  from  96°  to  104°  F.  The  condition  of 
these  patients  is  deplorable  and  the  prognosis  very  grave.  Eecovery  is  extremely 
rare. 

In  addition  to  constitutional  measures,  all  metastatic  foci  should  be  drained 
when  possible. 


CHAPTEE    XXXVI 

THE    SDEGICAL    DISEASES     (continued). ERYSIPELAS DIPHTHERIA — TETANUS HY- 
DROPHOBIA  HOSPITAL      GANGRENE ACTINOMYCOSIS ANTHRAX GLANDERS 

MALIGNANT    (EDEMA FOOT    AND    MOUTH    DISEASE — TUBERCULOSIS LEPROSY 


Erysipelas  is  an  infectious  inflammation  of  tlie  skin  and  subcutaneous  con- 
nective tissue,  or  of  tlie  mucous  membrane  and  submucous  tissue,  involving  especially 
the  lymph  channels  which  permeate  the  area  involved.  It  is  caused  by  a  specific 
micro-organism   (streptococcus  erysipelatis)    (Fehleisen)   which  effects  an  entrance 

through    an    abrasion    of    the    skin    or    mucous 

membrane.     It  proliferates  rapidly  and  spreads 

along  the  lymphatic  channels  (Fig.  784),  which, 

/  becoming    engorged,    break    down,    permitting 

^       ^    y  shoals  of  cocci  to  invade  the  intravascular  spaces. 

t  They  are  here  found  within  the  jDrotoplasm  of 

the  leucocytes  (phagocytosis)    (Fig.  785). 


y 


'  i/ 


Fig.  784. — Streptococci  of  erysipelas. 
X  700.  Section  through  a  lymph 
vessel  of  the  skin.     (Fliigge.) 


Fig.  7So. — Phagocytes  (Metschnikoff).  a,  an  anthrax  bacil- 
lus about  to  enter  a  white  blood-corpuscle;  b,  the  anthrax 
bacillus  within  the  wliite  blood-corpuscle ;  c,  white  blood- 
corpuscle  with  anthrax  bacilli  which  have  become  broken 
into  1  ' 


There  seems  to  be  a  close  relationship  Ijetwoen  erysipelas  and  puerperal  fever. 
The  organism  found  in  this  fever  cannot,  under  the  microscope,  be  differentiated 
from  the  streptococcus  of  Fehleisen.  Senn  claims  that  streptococci  ol^tained  from 
the  puerperal  uterus  when  injected  into  the  skin  cause  erysipelas,  and  vice  versa. 
While  the  coccus  of  erysipelas  closely  resembles  the  streptococcus  pyogenes,  experi- 
ments seem  to  demonstrate  their  essential  difference.  Injections  of  the  pyogenic 
cocci  produce  a  deep-seated,  widespread  inflammation  with  general  infiltration, 
while  the  erysipelas  cocci  are  chiefly  found  in  the  lumen  of  the  lymph  vessels. 

In  its  incipiency  the  skin  is  in  color  a  bright  red,  and  presents  a  smooth  and 
glazed  appearance.  The  line  of  redness  is  usually  sharply  defined,  not  fading 
gradually  into  the  normal  skin  as  in  simple  dermatitis.  The  color  is  deeper  in 
the  center  of  infection,  at  times  assuming  a  dark,  mottled  hue.  There  is  marked 
increased  local  heat,  with  throbbing  and  sharp  burning  pain,  with  usually  high 
temperatures,  chills,  or  rigors. 

In  simple  cutaneous  erysipelas  the  S3anptoms  are  usually  mild,  and  the  tendency 
is  to  recovery  in  from  four  to  six  days.  With  a  low  resistance,  and  when  the 
infection  is  virulent,  hiillce.  due  to  exudation  of  serum  in  the  Malpighian  layer, 
may  appear,  or,  the  subcutaneous  connective  tissues  being  involved,  mixed  infec- 
tion with  the  formation   of   pus   may  result    (phlegmonous   erysipelas).     In  the 

744 


THE   SURGICAL   DISEASES 


745 


severer  forms  of  infection,  where  the  leucocytes  are  overwhelmed,  gangrene  may 
result  (gangrenous  erysipelas). 

Diagnosis. — Erysipelas  occurs  more  frequently  upon  the  face,  especially  about 
the  muco-cutaneous  surfaces  of  the  nose,  where  abrasions  are  frequent.  It  may 
be  mistaken  for  dermatitis  or  simple  erythema,  phlebitis,  lymphangitis,  or  cellulo- 
dermatitis.  Dermatitis  occurs,  as  a  rule,  from  local  irritation,  and  is  not  accom- 
panied by  any  marked  constitutional  disturbance.  While  the  skin  is  red,  it  does 
not  present  the  glazed  appearance  which  is  typical  of  erysipelas,  nor  the  sharply 
defined  borders.  In  erythema  papulatum,  which  usuallj^  attacks  the  exposed  and 
extensor  surfaces,  as  the  dorsum  of  the  hand  and  the  posterior  aspect  of  the  fore- 
arm (almost  always  in  children  and  adults),  there  is  no  focus  of  inoculation,  and 
very  slight  infiltration  of  the  skin,  iloreover,  the  papules,  commonly  observed  in 
erythema,  are  rarely  found  in  erysipelas. 

In  phlebitis  and  lymphangitis  the  march  of  the  infection  is  rapidly  along  the 
liaes  of  these  vessels.     It  does  not  spread  in  a  circular  area,  as  does  erysipelas. 

Diffuse  cellulitis  is  caused  by  an  infected  wound,  and  is  almost  always  accom- 
panied b}'  rapid  pus  formation. 

Treatment. — The  streptococcus  of  erysipelas  is  destroyed  in  1-1000  mercuric- 
chloride  solution.  If  the  disease  is  recognized  within  the  first  few  hours  of  infec- 
tion, a  hypodermic  injection  of  the  solution  into  the  substance  of  the  skin  involved, 
and  slightly  beyond  the  area  of  redness,  would  retard,  and  might  prevent,  further 
invasion.  If  a  one-per-cent  cocaine  solution  were  first  injected,  tlie  sharp  pain 
of  the  mercuric-chloride  instillation  would  be  lessened.  This  treatment  could  only 
be  jiistified  where  the  circle  of  injection  would  not  require  a  sufficient  quantity 
of  the  mercuric  solution  to  endanger  systemic  poisoning. 

Lattice-work  incisions  (Fig.  786),  commencing  one  half  inch  from  the  margin 
of  redness  and  completely  surrounding  the  area  of  infection,  tend  to  arrest  the 
further  spread  of  the  disease.  These  incisions,  made  with  a  sharp  scalpel,  should 
not  go  deeper  than  about  half-way  through  the  skin.  Cocaine  instillation  (one 
to  one  half  of  one  per  cent)  should  be  employed  to  deaden  sensation.  It  is  advisa- 
ble to  cover  these  incisions  with  several  layers  of  flexible  collodion.  Compresses, 
wet  in  1-1000  sublimate  solution,  should  be  applied  as  an  after-treatment.  The 
bowels  should  be  kept  open,  the  patient  .  ^  /  / 

carefully  nourished.  Ten  to  fifteen  hn.a-rs(^  J/  p-y'^sr/eMoc^s  redms^ 
grains  of  C[uinia  and  tincture  of  chlo- 
rate of  iron  are  recommended.  Upon 
an  extremity  an  elastic  bandage,  ap- 
plied above  and  below  the  focus  of  in- 
fection, tight  enough  to  constrict  the 
superficial  lymphatics  and  veins,  will 
retard  the  spread  of  the  disease  and 
may,  after  the  theory  of  Bier,  produce 
localized  leucoeytosis  with  destruction 
of  the  special  pathogenic  organisms. 
Isolation  and  antisepsis  are  imperative. 
The  hands  of  the  attendant  should  be 
protected  with  rubber  gloves,  the  body 
and  clothing  shielded  with  a  gown  moistened  in  1-1000  bichloride  solution.  _  The 
head  and  face  should  also  be  protected  when  in  attendance,  and  when  this  is  not 
done,  a  careful  washing  with  bichloride  solution  should  be  practiced. 

A  knowledge  of  the  fatal  character  of  puerperal  fever  resulting  from  strepto- 
coccus infection  should  forbid  attendance  upon  an  obstetric  case  by  one  m  charge 
of  an  erysipelatous  patient.  All  dressings  should  be  burned  or  boiled,  all  instru- 
ments, bedding,  clothes,  etc.,  subjected  to  germ-destroying  heat 

Diphtheria  is  an  infectious  disease  caused  by  the  Klebs-Loeftier  baciUus  diph- 
theria,^ attacking  usually  the  mucous  meml^rane  of  the  tonsils,  pbarjTix,  fauces, 

I  There  is  not  infrequently  found  a  pseudo-bacillus  which  infests  the  tonsils  and  contiguous 
mucous  surfaces.  It  closely  resembles  the  true  diphtheritic  germ.  When  discovered  m  cultures 
from  a  suspicious  subject  rigid  antiseptic  local  treatment  should  be  mstituted. 


Fig.  786. — Zigzag  incisions,  actual  length. 
(After  "Willy  Meyer.) 


746  THE   SURGICAL   DISEASES 

larynx,  and  occasionally  the  nasopliarynx.  It  may,  however,  effect  a  lodgment  in 
an  abrasion  upon  the  skin  or  mucous  membrane  in  any  part  of  the  body.  This 
bacillus  is  slightly  curved,  with  rounded  ends,  2  to  3  /x  in  length,  with  a  diameter 
of  0.8  IX..  It  is  rejjroduced  by  fission,  is  aerobic  and  non-motile.  It  resists  desic- 
cation for  weeks,  and  even  when  thoroughly  dried  will  reproduce  itself  in  a  suit- 
■able  medium.  The  toxic  products  of  the  bacillus  diphtheria  are  readily  absorbed 
by  the  blood,  in  severe  cases  impairing  the  function  of  the  red  blood  corpuscles. 
This  poison  also  affects  the  tissues  in  general,  and  especially  disturbs  the  nutrition 
of  the  nerve  cells,  causing  the  frequent  paralyses  associated  with  diphtheritic  sepsis. 
Mixed  infection  due  to  the  passage  into  the  blood  of  i33'ogenic  cocci  lodged  on  the 
ar,ea  infected  often  occurs  with  diphtheria. 

Symptoms. — The  symptoms  of  diphtheria  are  local  and  constitutional.  There 
is  usually  located  on  the  tonsils  a  characteristic  membrane  spreading  along  the 
fauces,  into  the  larynx,  and  upward  in  the  nasopharynx.  With  the  true  diphther- 
itic exudate  there  is  a  peculiar  odor  and  an  irritating  discharge,  swelling  of  the 
nearest  lymphatic  glands  (submaxillary,  as  a  rule),  and  a  tendency  to  bleeding 
where  the  membrane  is  becoming  detached.  It  is  closely  adherent  to  and  incor- 
porated with  the  superficial  epithelia  of  the  mucous  membrane.  In  non-diphtheritic 
■exudates  the  membrane  rests  upon  the  epithelia,  and  is  easily  removed  without  the 
bleeding  which  follows  the  more  virulent  disease. 

The  diagnosis  depends  upon  the  presence  of  the  specific  bacillus  as  shown  by 
cultures,  together  with  the  constitutional  symptoms,  the  most  positive  feature  of 
which  is  a  profound  prostration  which  is  out  of  all  proportion  to  the  fever  and 
the  local  manifestation.  The  pulse  is  usually  rapid,  the  temperature  is  high, 
although  in  rapidly  fatal  cases  it  may  be  normal,  and  often  subnormal.  The  kid- 
neys are  apt  to  be  involved  early  in  the  dis,ease.  Albumin  and  casts  appear  in 
the  urine  within  the  first  five  days.  There  is  occasionally  an  eruption  of  the  skin, 
varying  from  a  transient  rash  to  dark-red  spots  or  patches  (maculte). 

A  membranous  inflammation  located  in  the  larynx  is  almost  invariably  true 
diphtheria  (Holt).  When,  however,  a  laryngitis  follows  a  pseudo-membranous 
inflammation  of  the  tonsils,  nose,  and  pharynx,  occurring  as  a  complication  of 
measles  or  scarlet  fever,  it  is  more  frequently  due  to  a  streptococcus  infection  than 
to  the  diphtheritic  bacillus. 

Treatment. — Serum  therapy  must  be  accorded  the  flrst  place.  That  issued  by 
the  New  York  Board  of  Health  or  by  Behring  is  preferable.  It  will  keep  from 
three  to  six  months  without  deterioration.  A  slight  turbidit}^  and  some  floccular 
deposit  are  always  present  in  the  serum,  but  when  it  shows  a  milky  turbidity  or 
emits  an  odor  suggestive  of  decomposition,  it  should  not  be  used.  It  usually  comes 
in  phials  containing  5  c.c,  and  is  said  not  to  be  injured  by  freezing  or  extreme 
heat.  It  is  best  not  to  subject  it  to  extremes  of  temperature,  and  it  should  be  kept 
in  a  dark,  moderately  cool  f)lace.  The  injections  should  be  made  imder  careful 
antiseptic  precautions.     A  glass  syringe  with  a  piece  of  rubber  tubing  attached, 


Codman  &  Shurtleff, 
Boston. 


Fig.  787. — Syringe  for  serum  injection. 

and  a  good-sized  needle,  capable  of  carrying  the  serum  into  the  tissues,  makes  a 
simple  apparatus  that  can  be  thoroughly  cleansed  by  boiling  (Fig.  787).  Pro- 
fessor Holt  prefers  to  inject  a  small  quantity  of  the  concentrated  serum.  The 
dose  is  to  be  measured  not  by  the  amount  of  serum,  but  by  the  number  of  anti- 
toxine  units  it  contains.  A  child  under  two  years  of  age  should  receive  1,000  units 
in  a  severe  case  and  600  in  a  mild  case,  repeating  the  dose  in  from  eighteen  to 
twenty-four  hours  if  no  improvement  is  seen,  and  again  after  a  similar  interval, 


THE   SURGICAL   DISEASES 


747 


if  necessary.  A  child  over  two  years  of  age  should  have  1000  -units  in  a  mild  case 
as  an  initial  dose,  a  second  one.  being  rarely  necessary,  and  from  1500  to  2000 
units  in  a  severe  case,  rej^eating  the  dose  as  above  given.  With  a  concentrated 
serum,  2.5  c.c.  (38  minims)  give  1000  antitoxine  units.  Formerly  it  required 
one  third  of  an  ounce  of  Behring's  serum  to  obtain  this  number  of  units.  The 
mortality  ratio  has  been  very  greatly  diminished  by  this  treatment  of  diphtheria. 
The  serum  is  essentially  harmless,  but  to 
be  of  value  it  must  be  injected  early,  at 
least  during  the  first  three  days,  and  ear- 
lier in  a  laryngeal  case.  Properly  given, 
it  neutralizes  the  toxsemia  of  diphtheria 
and  controls  the  membranous  formation 
due  to  this  bacillus.  It  has  no  effect 
upon  general  septicsemia  or  streptococcus 
infection. 

In  employing  the  antitoxine,  heart  stimulants  are  indicated  whenever  required 
by  the  condition  of  the  pulse.  Every  child  exposed  to  diphtheria  should  receive 
an  immunizing  dose  of  the  serum,  100  to  300  units  being  given,  according  to  the 
age  of  the  child.     This  will  iisually  afford  protection  for  at  least  a  month. 

Local  treatment  is  not  advised  for  young  and  intractable  patients.  For  others, 
nasal  injections  of  warm  salt  solution  (for  cleanliness  only)  are  to  be  recommended 
in  nasal  and  nasopharyngeal  cases. 

Intubation. — In  the  surgical  treatment  of  the  tracheal  or  laryngeal  stenosis 
of  diphtheria,  intubation  has  practically  superseded  the  operation  of  tracheotomy. 


© 


Fig.  789. — Introducer.  jj 

This  innovation  is  due  to  the  late  Dr.  Joseph  O'Dwyer.     It  is 
indicated    when    there    is   progressive    and   persistent   dyspncea. 
It  is  performed  as  follows :  The  child  should  be  covered  from 
the  chin  down  with  a  light  blanket,  the  shoulders, 
arms,  and  hands  included.     The  attendant  hold- 
ing the  child  should  sit  in  a  straight  chair  bolt 
upright,  the  child  in  her  lap,  and  both  facing  the 
operator.     The  attendant  grasps  the  child's  elbows  firmly,  clasps  its        &-12A 
legs  between  the  knees,  securing  the  child  in  a  firm  grasp,  immobiliz- 
ing it  without  interfering  with  the  expansion  of  the  chest.     The  posi- 
tion of  the  child  should  be  as  though  it  were  suspended  from  the  top 
of  its  head.     Another  assistant  stands  behind  the  nurse  and  grasps 
the  child's  head  between  his  hands  in  order  to  hold  it  firmly,  and 
when  the  gag    (Fig.   788)   has  been  inserted  includes  it  within  his 
grasp  to  insure  its  steadiness.     The  operator,  sitting  squarely  facing 
the  child,  inserts  the  gag,  opens  the  mouth  widely,  and  gives  the 
handle  to  the  assistant.    With  the  introducer  (Fig.  789),  armed  with 
the  tube  of  proper  size,^  already  threaded,  the  operator  inserts  the 
index-finger  hooks  up  the  epiglottis,  crowds  the  finger  to  one  side, 

'  Dr.  d'Dwyer's  directions  are  as  follows:  The  tubes  are  of  various  sizes,  and 
are  constructed  on  a  scale  (Fig.  790)  somewhat  lilce  the  urethral  sounds.  No.  1  is 
intended  for  a  child  eighteen  months  old,  or  less ;  No.  2,  between  eighteen  months 
and  three  years;  No.  3,  for  the  fourth  year;  No.  4,  for  the  fifth  year,  and  so  on. 

When  the  proper  tube  is  selected  for  the  case  to  be  operated  on,  a  fine  silk 
thread  is  passed  through  the  small  hole  near  its  anterior  angle,  and  left  long 
enough  to  hang  out  of  the  mouth,  its  object  being  to  remove  the  tube  should  it 
be  found  to  have  passed  into  the  oesophagus  instead  of  the  larynx.  The  obtura- 
tor is  then  screwed  tightly  to  the  introducing  instrument,  to  prevent  the  possi- 
bility of  its  rotating  while  being  inserted,  and  passed  into  the  tube. 


I'iG.  790. 
Scale. 


748  THE  SURGICAL  DISEASES 

passes  the  tube  beyond  it  until  it  engages  in  the  chink  of  the  glottis,  elevates  the 
handle,  and  gently  jaresses  the  tube  down  till  the  head  is  within  the  box  of  the  larynx 
and  the  introducer  lies  crowded  upon  the  tongue.  He  then,  with  the  trigger,  loosens 
the  obturator,  holds  the  tube  with  the  left  index-finger  while  withdrawing  the 
obturator,  and  with  a  gentle  thrust  presses  the  tube's  head  well  into  the  larynx  and 
removes  the  finger  and  gag.  Always  keep  the  introducer  in  the  middle  line,  other- 
wise the  obturator  will  pinch  in  the  caliber  of  the  tube  and  draw  the  tube  with  it 
as  it  is  withdrawn.  The  handle  of  the  introducer  should  be  held  most  lightly  between 
the  end  of  the  thumb  and  finger.  In  this  way  it  is  impossible  to  use  enough  force 
to  make  a  false  passage.  It  is  easy  for  a  right-handed  operator  inadvertently  to 
carry  his  handle  to  the  left  of  the  child's  middle  line.  Everything  depends  upon 
the  coolness  and  skill  of  the  operator  and  the  absolute  quiet  of  the  child,  who  must 
be  firmly  and  immovably  held. 

"  Should  the  first  attempt  fail,  it  is  better  to  make  repeated  short  attempts  than 
one  prolonged  efliort.  When  the  tube  is  properly  lodged  in  the  larynx,  there  will 
be  some  rattling  on  the  first  respiration  and  subsequent  cough  and  expectoration. 
The  cough  argues  well  for  the  sensitiveness  of  the  parts,  and  the  gag  may  be 
removed  as  soon  as  the  tube  is  in  place,  but  the  thread  should  remain  until  all 
obstruction  to  breathing  has  been  overcome  and  the  physician  is  assured  that  there 
is  no  partially  detached  false  membrane  in  the  trachea  below  the  tube.  An  expert 
operator  can  remove  the  thread  in  the  course  of  ten  or  twenty  minutes,  but  since 
the  removal  of  the  tube  requires  a  good  deal  of  skill,  it  would  be  better  ordinarily 
to  leave  the  thread  in  for  the  purpose  of  removing  the  tube  when  the  time  comes. 
Children  with  teeth,  however,  are  apt  to  chew  the  thread  in  two  unless  it  is  sunk 
down  and  buried  between  two  teeth. 

"  To  remove  the  tube  when  the  thread  is  not  left  in,  the  child  should  be  held 
in  the  same  position  as  before;  carry  the  left  index-finger  past  the  epiglottis,  hook 
it  up,  rest  the  tip  of  the  finger  on  the  arytenoid  cartilages,  and  carry  the  extractor 
point  to  the  end  of  the  left  index-finger;  elevate  the  handle  so  that  the  point  will 
be  directed  forward  from  the  left  index-finger  on  the  arytenoid  into  the  aperture 
of  the  tube.  The  guard  screw  of  the  extractor  lever  should  be  carefully  set  to 
avoid  injury  to  the  tissues  in  case  the  extractor  jaws  should  be  opened  by  mistake 


in  the  soft  parts  instead  of  in  the  tubes.  As  to  the  time  of  removing 
the  tube,  it  depends  upon  the  age  of  the  child  and  the  condition  of 
respiration  as  afEected  by  the  disease;  the  average  is  about  five  days. 
Should  a  piece  of  false  membrane  be  loosened,  which  is  characterized 
by  a  croupy  cough,  rattling  due  to  obstruction  of  outgoing  air,  and  other  symptoms 
of  threatened  asphyxia,  the  tube  should  be  removed  at  once. 

"  Feeding  a  child  after  intubation  is  the  great  difficulty.  When  the  effort  of 
swallowing  is  accompanied  by  strangling,  the  child  should  be  laid  with  the  head 
lowered  so  that  it  swallows  uphill,  as  any  fiuid  which  gets  into  the  tube  during  the 
act  of  swallowing  quickly  runs  out.  The  child  should  be  fed  either  with  a  spoon 
or  a  nursing  bottle." 

Tetanus,  or  "  lockjaw,"  is  an  infectious  disease  caused  by  the  lodgment  in  a 
wound  of  the  skin  or  mucous  surface  of  a  specific  micro-organism  known  as  the 
tetanus  bacillus  of  Nicolier.  It  is  one  of  the  smallest  bacilli  and  develops  by 
sporulation.  The  spore  or  seed  developing  in  one  end  causes  this  to  swell,  giving 
the  rod  a  shape  like  a  tack  or  drumstick  (Fig.  792).  Its  habitat  is  the  soil, 
decomposed  fiuids,  manure,  and  in  the  purulent  discharge  of  a  person  affected 
with  this  disease.  The  infection  is  most  prevalent  between  May  and  October,  and 
especially  so  in  June,  July,  and  August  (Jacobson  and  Pease).  It  is  slightly 
motile,  and  is  classed  among  the  obligate  anaerobic  organisms — that  is,  it  cannot 


'ri: 


THE   SURGICAL   DISEASES  749 

live  where  it  comes  in  contact  with  the  ox3'gen  of  the  atmosphere.     It  is  difficult 
to  destroy  the  spores,  and  pus  containing  them  has  been  dried  for  sixteen  months, 
yet  produced  lockjaw  when  introduced  under  the  skin  of  animals.    They  are  readily 
killed  when  exposed  to  a  temperature  of  100°  C.  (312° 
F.).     The  toxic  product  or  ptomaine  of  the  tetanus 
bacillus,  separated  from  these  organisms  by  germ-free 
fUtration,  will,  when  introduced  into  the  blood  of  ani- 
mals, produce  typical  tetanus,  but,  as  with  other  toxic  Jt'A*'^^ 
products,  it  is  less  apt  to  prove  fatal,  since  the  symp-                    vV         * 
toms    are    only    temporary,    the    bacillus    itself    iDeing         |;^  ^ 
necessary  to  prolonged  sepsis.     The  bacillus  of  JSTieo-               \      .    "  ^^  ^""^ 
lier,  so  far,  has  not  been  found  in  the  blood  or  in  any                      \   ^ 
of  the  central  organs.     It  is  evident,  therefore,  that  it                        ^      ^ 
remains  near  the  wound  of  infection,  where  it  gener-  . 
ates  a  violent  poison,  which  is  absorbed  and  produces       ^°spores7rom^an\gar  culture, 
rapid  infection   and   the   convulsions   peculiar   to   this          x  i,ooo.    (Kitasato.) 
disease. 

The  time  which  may  elapse  between  the  receipt  of  the  injury  and  the  appear- 
ance of  the  muscular  spasms  varies  from  a  few  hours  to  several  weeks ;  usually 
within  the  first  three  weeks  after  the  injury.  The  earlier  symptoms  refer  to  an 
unusual  degree  of  irritation  and  pain  in  the  wound,  which  is  apt  to  be  out  of 
proportion  to  the  degree  of  inflammation  present.  The  sense  of  pain  is  often 
referred  along  the  sensory  tracts  toward  the  centers.  Irritability,  a  sense  of  un- 
usual muscular  excitability,  a  feeling  of  malaise  and  apprehension,  are  among  the 
symptoms  which  precede  the  convulsive  attacks.  The  muscles  supplied  by  the 
motor  filaments  of  the  fifth  nerve  are  among  the  earliest  to  respond  to  this  abnor- 
mal stimulus,  hence  the  commonly  accepted  term  of  lockjaw.  In  the  milder  cases 
the  tonic  spasm  may  be  altogether  confined  to  these  muscles.  In  severer  cases  the 
sense  of  distress  is  referred  to  the  epigastric  region,  and  this  is  followed  by  tonic 
muscular  contraction,  commencing  with  the  diaphragm,  and  involving  in  quick 
succession  the  muscles  of  the  jaws,  larynx,  and  back  of  the  neck  and  dorso-lumbar 
region.  Eespiration  is  interrupted,  the  expression  of  distress  is  extreme,  the  face 
becomes  cyanotic,  and  death  may  occur  from  fixation  of  the  respiratory  muscles. 
The  chief  distortion  is  that  of  more  or  less  complete  extension  of  the  spine  (opis- 
thotonos). When  the  tonic  spasms  are  confined  to  the  anterior  muscles,  and  the 
body  is  bent  forward,  the  condition  is  known  as  emprosthotonos,  and  if  curved 
laterally,  plewothoto7ios.  The  spasm  continues  until  the  muscles  are  unable  longer 
to  contract,  when  a  gradual  and  partial  relaxation  occurs.  Successive  attacks 
follow  rapidly,  being  precipitated  by  the  slightest  cause,  as  the  jar  communicated 
by  walking  upon  the  floor,  or  the  contact  of  the  hair  or  dothing  upon  the  hyper- 
ffisthetic  integument.  Occasionally  the  muscles  near  the  infection  are  first  seized 
with  convulsions,  as  in  the  muscles  of  the  calf  when  the  foot  is  the  seat  of 
lesion. 

Notwithstanding  the  violent  nature  of  this  affection,  the  mind,  in  the  great 
majority  of  cases,  remains  clear  until  carbonic-acid  poisoning  occurs  from  pro- 
longed fixation  of  the  respiratory  muscles.  The  pulse  and  temperature  vary  be- 
tween great  extremes,  records  of  the  former  running  from  the  normal  up  to  160 
beats  per  minute,  and  of  the  latter  from  98.5°  to  112°  F.  The  intense  heat  which 
is  premonitory  of  a  fatal  termination,  and  which  continues  for  a  considerable 
while  after  death,  is  supposed  to  be  due  to  coagulation  of  the  albuminoid  principle 
of  muscle,  the  myosin  (Fricke).  Death  may  take  place  in  a  single  paroxysm,  or 
the  patient  mav  survive  a  number  of  attacks. 

Prognosis.— The  gravity  of  the  prognosis  usually  depends  upon  the  violence 
of  the  paroxysms,  the  rise  in  pulse  and  temperature  being  also  proportional  to- 
the  severity  of  the  convulsions.  The  period  which  elapses  between  the  receipt 
of  the  accident  and  the  appearance  of  the  tetanic  spasms  is  not  without  importance 
in  prognosis,  the  chances  of  recovery  being  increased  with  the  longer  interval. 

Diagnosis. — Hysteria  is  more  apt  to  be  mistaken  for  tetanus  than  any  other 
disease.     In  hvsteria  there  is  usually  no  elevation  of  temperature,  and  the  symp- 


750  THE   SURGICAL   DISEASES 

toms  of  great  and  acute  distress  are  wanting.  Hysteria  occurs  chiefly  in  females ; 
tetanus,  in  a  large  majority  of  cases,  in  the  opposite  sex.  It  may  be  necessary  at 
times  to  differentiate  between  the  tetanoid  spasms  of  strychnia  poisoning  and 
true  tetanus. 

Strychnia  tetanus  ensues  within  a  few  minutes  after  the  poison  has  been  taken ; 
the  muscles  of  the  jaw  are  not  first  affected  as  in  tetanus,  and  are  not  always  rigid 
during  the  attack.  The  convulsive  movements  in  strychnia  poison  are  of  short 
duration,  and  complete  relaxation  occurs,  while  in  tetanus  the  muscular  rigidity 
is  continuous. 

Hydrophobia  may  be  distinguished  from  tetanus  in  the  character  of  the  lesion 
which  causes  it,  the  peculiar  clonic  or  interrupted  spasm  of  the  muscles,  espe- 
cially those  of  the  larynx,  and  in  the  generally  longer  period  of  incubation  in 
rabies. 

The  post-mortem  changes  are  chiefly  noticeable  in  the  spinal  cord  where  there 
occur  extravasations  of  blood  in  the  interstitial  connective  tissue  of  the  cord  and 
peripheral  nerves  and  a  granular  infiltration  of  the  nerve  cells  (Tillmanns).  In 
the  wound  there  is  hypertemia  and  swelling  and  usually  great  pain.  Suppuration 
does  not  occur  unless  some  pyogenic  organism  has  produced  in  the  wound  a  mixed 
infection. 

Treatment. — The  immediate  immersion  of  a  superficial  wound  in  a  solution 
of  mercuric  chloride,  1-500,  within  a  few  minutes  of  its  receipt  (especially  if . 
constriction  has  been  applied)  will  destroy  the  tetanus  bacillus  as  well  as  any  other 
pathogenic  micro-organisms.  After  a  delay  of  fifteen  or  twenty  minutes,  or  in 
a  case  of  a  deep  wound  or  puncture,  especially  when  earth  or  farmyard  manure 
has  been  in  contact,  washing  away  of  the  dirt,  the  removal  of  all  foreign  matter, 
and  thorough  cauterization  with  fuming  nitric  acid,  should  be  made  as  advised 
in  hydrophobia.     Cocaine  infiltration  should  be  employed  to  deaden  sensibility. 

The  germs  of  lockjaw  lodge  immediately  in  the  wounded  area,  where,  under 
proper  condition's,  they  proliferate  and  generate  a  toxine  which  is  absorbed  and 
carried  into  the  tissues,  producing  the  convulsions  which  are  common  to  this 
disease.  When  there  is  a  deep  puncture,  as  from  a  nail  thrust  in  the  sole  of  the 
foot,  this  should  be  enlarged  so  that  every  portion  of  the  wound  may  be  subjected 
to  thorough  cauterization.  If  infection  has  been  established  before  the  wound  is 
seen  by  the  surgeon,  several  cauterizations  may  be  necessary,  the  eschar  from  the 
first  treatment  being  removed  by  the  curette. 

Within  recent  years  treatment  of  this  disease  by  the  use  of  a  tetanus  antitoxine 
has  been  generally  approved.  According  to  E.  T.  Hewlett,  tetanus  antitoxine  is 
■  obtainable  in  three  forms,  viz.,"  (l)"hlood  serum;  ;(3)  dry  form,  one, gramme  of 
which  corresponds  to  ten  cubic  centimetres  of  the  serum;  (3)  the  serum  may  be 
precipitated  with  alcohol,  and  the  precipitate  dried  (Tizzoni's  antitoxine),  which 
is  the  most  concentrated  form  (Senn).  The  dose  varies  from  five  or  sis  cubic 
centimetres  to  as  high  as  one  hundred  and  sixty-seveU;  cubic  centimetres.  This 
quantity  was  given  by  Eoux,  and  caused  no  general  disturbance  l^eyond  producing 
urticaria.  Such  a  large  dose  will  rarely  be  required.  Henle  recommends  from 
twenty  to  forty  centimetres  of  the  fluid  serum,  for  the  first  day,  followed  by  ten 
to  twenty  cubic  centimetres  everj^  six  to  twelve  hours  afterward,  (One  gramme  of 
dry  serum  is  equal  to  ten  cubic  centimetres  of  the  fluid  serum.)  With  Tizzoni's 
antitoxine  the  dose  is  two  grammes  to  begin  with,  and  0.6  of  a  gramme  in  subse- 
quent doses.  It  is  administered  by  hypodermic  injection  with  a  syringe  sufficiently 
large  to  necessitate  only  a  single  puncture.  Antiseptic  precautions  should  be 
taken  in  its  administration.  It  should  be  given  as  soon  as  the  disease  is  recog- 
nized. The  quantity  necessary  will  increase  rapidly  with  the  duration  of  the 
disease. 

Antitetanic  serum,  which  may  now  be  readily  obtained, "■  is  administered  by 
hypodermic  injection  in  doses  of  ten  cubic  centimetres,  repeated  every  six  hours 
until  improvement  is  manifest,  and  then  at  longer  intervals  until  recovery  is 
assured.  Even  in  a  wound  such  as  that  caused  by  the  lodgment  of  a  fragment 
of  cartridge  or  shell,  or  any  deep  abrasion  whiclr  has  Ijeen  in  contact  with  foul 
'  Parke,  Davis  &  Co. 


THE   SURGICAL   DISEASES 


751 


earth,  the  prophylactic  use  of  this  remedy  is  advised,  and  at  the  same  time  the 
wound  should  be  treated  in  the  thorough  manner  already  given.^ 

In  seemingly  hopeless  eases  the  intraspinal  injection  of  this  serum  may  be 
entertained.  Dr.  W.  H.  Luckett  has  reported  two  cases  in  which  this  agent  was 
employed  and  in  which  recovery  ensued.  Under  careful  asepsis  the  puncture  was 
made  between  the  third  and  fourth  lumbar  vertebra;.  Twenty-two  drops  of  cerebro- 
spinal fluid  were  withdrawn  and  eight  cubic  centimetres  of  the  serum  injected. 
On  the  second  day,  t«-elve  drops  were  withdrawn  and  eleven  cubic  centimetres  of 
the  antitoxine  used.  On  the  fourth  day,  forty  drops  were  withdrawn  and  ten 
cubic  centimetres  injected.  The  injection  should  be  made  very  slowly,  consuming 
from  five  to  ten  minutes  in  emptying  the  syringe.  In  one  case,  Luekett  withdrew, 
in  all,  one  hundred  and  sixty-one  drops  of  cerebrospinal  fluid  and  injected  in  the 
course  of  the  treatment  a  total  of  ninetv'-two  cubic  centimetres  of  antitetanic  serum ; 
in  another,  six  hundred  and  five  drops  of  fluid  were  drawn  and  fifty-nine  cubic 
centimetres  injected. 

The  general  treatment  is  to  keep  the  patient  quiet,  and  by  thoroughly  emptying 
the  alimentary  canal  to  place  the  digestive  apparatus  in  the  best  possible  condition 
for  absorbing  nourishment. 

The  administration  of  chloral  hydrate,  from  forty  to  seventy  grains  at  a  dose 
per  rectum,  has  been  recommended.  The  percentage  of  deaths  among  cases  so 
treated,  as  given  by  Kane,  was  ninety-four  out  of  one  hundred  and  thirty-four. 
Tillmanns  states  that  in  ninety-three  cases  treated  with  chloral  hydrate  in  com- 
bination with  other  remedies,  there  were  thirty-three  deaths.  The  patient  should 
lie  placed  in  a  dark  room,  the  ears  plugged  -nith  cotton  in  order  to  shut  out  all 
sound,  and  no  one  should  be  allowed  to  approach  the  bed  except  in  the  most  care- 
ful and  noiseless  manner.     The  isolation  should  be  as  absolute  as  possible. 

Dr.  W.  E.  Bross,  in  a  considerable  experience  in  Central  America,  found  the 
most  efficient  remedy  to  be  tartar  emetic,  in  doses  of  from  one  fourth  to  one  sixth 
grain  every  two  or  three  hours.  '    : 

Dr.  David  St.  John  reports  a  number  of  cases  of  lockjaw  (and  also  of  cerebro- 
spinal meningitis)  successfully  treated  by  this  remed}^- 

Dr.  Joseph  A.  Blake  ("Annals  of  Surgery,"  1906)  reports  that  magnesium  sul- 
phate modifies  the  convulsions  and  relieves  the  pain  in  a  way  no  other  drug  has 
approached.  It  is  injected  into  the  areolar  tissue,  one  cubic  centimetre  of  a  t'wenty- 
five-per-cent  solution  for  every  twenty-four  pounds  of  body  weight.  An  anaesthetic 
is  required. 

Hydrophobia  is  an  infectious  disease,  acquired  with  the  bite  of  a  dog,  wolf,  cat; 
fox,  or  other  animals  in  these  groups."  The  specific  organism  belongs  to  the  pro^ 
tozoa.  In  shape  it  is  round  or  oval,  varying  in  size,  the  largest  measuring  about 
twenty-five  ii."  Under  the  microscope  it  appears  to  contain  granules  and  is  some- 
what vacuolated.  It  is  introduced  with  the  puncture  of  the  tooth,  and  ulti- 
mately finds  a  proliferating  ground  in  the  central  nervous  system,  especially  in  the 
brain  and  in  that  particular  portion  of  the  cerebrum  Icnown  as  the  hippocampus 
major  (William  Litterer).  They  are  occasionally  found  in  the  substance  of  the 
spinal  cord,  in  the  spinal  ganglia,  and  in  the  ganglion  of  Gasser,  but  nowhere  with- 

■  In  the  St.  Louis  City  Dispensary,  Dr.  H.  J.  Scherck  reports  sixteen  deaths  out  of  fifty-six 
cases  in  190.3  when  no  antitetanic  serum  was  used.  In  1906,  170  cases  were  treated  with  the 
antitetanic  serum  •nnth  no  deaths. 

2  "Transactions  of  the  140th  Session  of  the  Medical  Society  of  New  Jersey."  The  diagnosis 
of  some  of  these  interesting  cases  was  confirmed  by  Dr.  Carlos  F.  MacDonald  and  Dr.  George  F. 
Shrady.  G.  W.,  aged  fifty-three  years,  had  his  finger  crushed  September  28,  1898;  the  wound 
became  infected  on  October  10th.  stiffness  of  the  jaw  developed  and  on  the  following  day  in  the 
abdominal  muscles  and  those  of  the  right  leg.  By  October  ISth,  the  patient  was  much  exhausted 
by  frequent  tetanic  spasms,  perspiration  was  profuse,  thirst  intense  and  respiration  labored. 
Tartar  emetic  one  quarter  grain  every  two  hours,  with  morphia  was  administered.  On  the 
following  day  the  patient  seemed  somewhat  less  uncomfortable,  and  not  so  rigid.  October  20th, 
pulse  118,  temperature  100°  F.,  catheterization  necessarj',  several  spasms  during  the  day.  October 
21st  under  chloroform  narcosis,  the  injured  finger  was  amputated.  October  23d  the  patient 
delirious,  attempting  to  get  out  of  bed  and  had  severe  comTilsions  with  most  marked  opisthotonos. 
From  this  time  he  gradually  improved  under  the  continuous  use  of  the  tartar  emetic  and  morphia 
and  finallj^  recovered. 

3  A  micron  (fi.)  is  jxiro  of  an  inch. 


752  THE   SURGICAL   DISEASES 

such  constancy  as  in  the  brain  (Dr.  Ira  Van  Gieson).  According  to  Tillmanns, 
ninety  per  cent  of  cases  in  man  result  from  the  bite  of  the  dog,  four  per  cent 
from  cats  and  wolves,  two  per  cent  from  foxes. 

The  period  of  incubation  varies  from  a  few  days  to  several  weeks  or  months, 
occasionally  longer.  The  earlier  symptoms  are  a  feeling  of  uneasiness  and  depres- 
sion; in  rare  instances  pain  is  felt  in  the  scar  of  the  wound,  and  this  is  followed 
by  convulsive  movements  of  the  pharj'ngeal  and  respiratory  muscles.  The  reflexes 
are  all  exaggerated.  Convulsive  seizures  gradually  increase  in  severity,  and  death 
follows  from  exhaustion  due  to  inability  to  swallow  as  well  as  from  the  depressing 
action  of  the  toxine. 

Treatment. — The  immediate  indication  is  to  neutralize  the  virus  at  the  point 
of  inoculation.  In  a  superficial  wound  thorough  cauterization  within  the  first 
twenty-four  hours  will  in  all  probability  effect  a  cure.  The  proper  remedy,  accord- 
ing to  Dr.  D.  W.  Poor,  is  fuming  nitric  acid  thoroughly  applied  to  all  parts  of 
the  wound  by  means  of  a  capillary  pipette,  which  is  more  satisfactory  than  the 
glass  rod.  As  the  application  is  intensely  painful,  preliminary  subcutaneous  infil- 
tration with  cocaine  or  quinia  solution  should  be  done.  With  a  deep  puncture  of 
the  tooth  or  an  extensive  tear,  great  care  should  be  taken  to  have  the  acid  find 
its  way  to  the  remotest  portions  of  the  laceration. 

Dr.  Poor  advises  the  application  of  nitric  acid  even  after  twenty-four  hours, 
adding  that  in  cases  where  the  Pasteur  treatment  cannot  be  applied,  great  benefit 
may  be  derived  from  the  correct  use  of  this  agent. 

When  nitric  acid  is  not  obtainable,  carbolic  acid  very  thoroughly  rubbed  in, 
or  the  actual  cautery,  should  be  substituted.  In  view  of  the  safety  of  this  treat- 
ment, and  in  its  assurance  of  immunization  from  the  more  remote  and  terrible 
conseqiiences  of  hydrophobia,  it  would  be  a  wise  precaution  to  treat  every  case  of 
dog  bite  by  immediate  cauterization  with  nitric  acid. 

The  diagnosis  can  only  be  made  positive  by  the  examination  of  the  brain  of  the 
animal  which  has  inflicted  the  wound,  and  this  should  in  all  cases  be  done  at 
once,  so  that  the  positive  knowledge  of  the  character  of  the  lesion  may  be  known 
and  rigorous  treatment  instituted. 

In  1903  Dr.  A.  Negri,  of  Italy,  discovered  certain  bodies  which  he  took  to  be 
protozoa  and  the  specific  organism  of  rabies.  It  is  advised  to  make  examinations 
from  several  portions  of  the  brain,  selecting  first  the  hippocampus  major,  then 
other  portions  of  the  brain,  and  lastly  the  cord  and  ganglia,  for  it  has  been  shown 
by  Negri  that  when  animals  were  inoculated  in  the  sciatic  nerve  these  bodies  were 
with  difficulty  discernible  in  the  hippocampus,  but  were  abundant  in  the  spinal 
cord  and  spinal  ganglia  (Litterer^). 

The  staining  solution  recommended  by  Dr.  Ira  Van  Gieson  and  Dr.  Williams  ^ 
is  Lceffler's  methylene  blue,  two  cubic  centimetres ;  distilled  water,  ten  cubic  centi- 
metres, and  a  saturated  alcoholic  solution  of  basic  fuchsin,  three  minims.  By  this 
stain  the  protoplasm  of  the  cell  body  is  stained  a  light  pink,  the  nuclei  a  light 
blue,  the  nucleoli  a  dark  blue,  the  red  blood  cells  a  light  yellow,  while  the  Negri 
bodies  stain  a  dark  red.  A  well-stained  specimen  will  show  in  these  bodies  a  few 
very  small  dark-blue  dots  called  chromatoid  granules.^ 

In  an  emergency,  where  the  diagnosis  cannot  be  immediatelj'  assured  by  the 
destruction  of  the  animal  and  by  examination  for  these  pathognomonic  bodies,  the 
wound  should  be  treated  as  above  directed.  The  animal  should  be  killed  and  the 
brain  preserved  in  fifty-per-cent  alcohol,  bottled,  and  shipped  at  once  to  the  nearest 
laboratory. 

'  "Southern  Practitioner,"  1907. 

=  Dr.  Van  Gieson  also  recommends  the  following  stain  and  method  for  the  quick  recognition  of 
the  Negri  bodies :  To  ten  cubic  centimetres  of  distilled  water,  add  two  drops  of  a  saturated  alcoholic 
solution  of  rose  anilin  violet  and  two  drops  of  saturated  aqueous  solution  of  methylene  blue  diluted 
one  half  with  water.  A  portion  of  the  suspected  gray  matter  about  the  size  of  a  bird  shot  is  placed 
on  one  end  of  the  slide  covered  with  a  cover-glass,  gently  squeezed  out  with  the  ball  of  the  finger 
and  the  cover-glass  shifted  across  the  slide,  making  a  smear.  These  squeeze  smears  are  stained  by 
pouring  a  few  drops  of  staining  solution  over  them,  holding  the  cover-glass  over  the  flame  until 
the  dye  steams.  They  are  next  rinsed,  dried  in  the  air  and  are  then  ready  for  the  microscope. 
"The  Negri  bodies  take  a  distinctive  deep  crimson  color  with  their  chromatin  particles  blue." 

3  "Medical  Record,"  August  11,  1907. 


THE   SURGICAL   DISEASES 


753 


_  By  experiments  upon  animals,  Pasteur  obtained  an  antitoxine  of  rabies  whicli 
IS  now  generally  accepted  in  the  therapy  of  this  disease.  By  the  use  of  this  sub- 
stance he  was  able  to  immunize  healthy  dogs  from  the  bite  'of  those  known  to  be 
mad.  This  fluid  of  proper  strength,  which  is  injected  subcutaneously,  by  prefer- 
ence m  the  abdominal  wall,  should  be  fresh  and  absolutely  sterile.  The  iniections 
should  be  mild  m  character  for  the  first  treatment,  increasing  the  quantity  arad- 
ualiy  lor  three  or  tour  days. 

Hospital  gangrene  has  "practically  disappeared  since  the  introduction  of  anti- 
septic surgery.  Although  it  is  believed  to  be  due  to  a  streptococcus  infection  no 
special  germ  has  yet  been  recognized.  Among  the  wounded  durino-  the  Civil  War 
and  especially  those  long  subjected  to  insufficient  food  and  unhv|ienic  surround- 
ings, It  created  great  havoc.  The  most  successful  treatment,  as  given  bv  Prof 
Frank  H.  Hamilton,  who  had  a  large  experience  in  that  period,  was  the  destruction 
of  the  mtected  area  with  the  actual  cautery,  or  preferably  by  the  free  use  of 
pure  bromine. 

Actinomycosis,  a  disease  quite  common  in  animals,  is  occasionally  met  with 
m  man.    It  is  caused  by  the  presence  of  the  ray  fungus  (Fig.  793).     To  the  naked 

eye  this  is  about  the  size  and  shape  of 
a  millet  seed,  yellowish-bro^vn  or  green- 
ish in  color,  soft  in  consistence.  Under 
the  microscope  it  consists  of  clusters  of 
wavy,  bushy  shreds,  or  club-shaped 
projections.  The  most  common  seat 
of  infection  in  man  is  the  mouth.  It 
may,  however,  be  engrafted  upon  any 
abrasion  of  the  skin.  It  is  character- 
ized by  inflammation  and  swelling  of  a 
low  and  slowly  developing  type  with 
the  formation  of  serum  and  pus.  The 
fungus  is  not  a  pyogenic  organism,  the 
pus  being  due  to  a  mixed  infection. 


Pig.  793. — Actinomyces  (ray  fungus)  with  one 
branching  filament  separated  from  tiie  otliers, 
(Ponfick.) 


Fig.  794. — Blood  from  a  mouse  witVi  anthrax, 
dried  on  the  cover-glass  and  stained  with 
methvl  violet.  Red  blood-corpuscles  and  an- 
thrax bacilli.       X  700.      (Koch.) 


The  diagnosis  rests  upon  the  recognition  of  the  peculiar  millet-seed  particles 
found  in  the  discharge.  If  not  visible  to  the  naked  eye,  the  microscope  will  reveal 
its  presence.  The  disease  may  attack  the  lungs  through  the  respiratory  tract,  or 
find  a  focus  of  infection  through  the  alimentary  canal. 

The  indications  in  treatment  are  to  destroy  the  focus  of  infection  by  the  use 
of  escharoties,  such  as  nitrate  of  silver  or  mercuric-chloride  solution.  The  iodine 
of  potassium  internally  administered  in  large  doses  has  proved  curative  in  a  num- 
ber of  cases,  and  should  be  faithfully  tried  before  resorting  to  operation.  Dr. 
A.  D.  Bevan  advises  sulphate  of  copper,  gr.  -J-gr.  j  t.  i.  d.  internally,  while  the 
sinuses  are  to  be  irrigated  with  one-per-cent  solution  of  the  same. 

Anthrax  ("  milzbrand,"  "splenic  fever,"  "  charbon,"  "malignant  pustule"), 
a  disease  of  animals,  is  occasionally  met  with  in  man.  It  is  caused  by  a  specific 
germ,  the  bacillus  of  anthrax  (Fig.  794).  Infection  in  man  is  most  frequently 
through  an  abrasion  of  the  skin  or  the  hair  follicles,  and  occasionally  through  the 
respiratory  tract.     Those  engaged  in  handling  raw  hides  or  caring  for  animals 


754 


THE   SURGICAL   DISEASES 


are  most  frequently  infected.  The  bite  of  flies  has  been  known  to  convey  this 
organism  into  the  body.  Incubation  is  from  a  few  hours  to  as  many  days.  As 
a  rule,  infection  is  rapid.  When  seen  at  the  earliest  stages  the  disease  may  be 
arrested  by  crucial  incisions  under  cocaine  anaesthesia  and  the  injection  of  ten 
to  fifteen  minims  of  1-1000  mercuric-chloride  solution.  In  neglected  cases  the 
tissues  become  gangrenous,  there  is  high  fever,  vomiting,  and  the  usual  symptoms 
of  severe  infection.  The  local  application  of  a  compress  in  ninety-per-cent  alcohol 
is  also  recommended.  In  severe  infection,  Sclavo's  serum,  thirty  to  forty  cubic 
centimetres  injected  hj'podermically,  has  been  successfully  employed.  In  seem- 
ingly hopeless  cases  the  intravenous  injec- 
tion of  this  remedy  may  be  tried.  It  is 
claimed  to  be  harmless  even  in  very  large 
doses. 

Glanders  (farcy)  is  a  disease  chiefly  of 
horses,  but  it  can  be  transmitted  to  man. 
It  is  caused  by  a  specific  non-motile  rodlike 
bacillus  (Fig.  795).  Infection  takes  place 
through  an  abrasion  of  the  skin  or  mucous 
membrane,  and  it  is  believed  it  may  enter 
and  effect  a  lodgment  through  the  hair 
follicles.  It  not  infrequently  attacks  the 
conjunctiva  and  the  mucous  membrane  of 
the  nose,  although  it  is  most  frequently  met 
with  in  the  integument.  The  acute  form 
is  accompanied  with  all  the  symptoms  of 
general  sepsis.  The  lymph  glands  are  en- 
larged and  usual  pyogenic  infection  is  also  present.  Metastases  in  the  spleen,  liver 
and  other  organs  may  occur. 

The  diagnosis  must  depend  iipon  the  peculiar  appearance  of  the  nodes  and  the 
association  of  the  person'  attacked  with  animals  known  to  have  the  disease.  In 
the  treatment  it  is  essential  to  destroy  as  early  as  possible  the  germs  at  the  seat 
of  infection.  Free  incision,  the  use  of  the  Paquelin  cautery,  or  the  instillation  of 
1-1000  mercuric-chloride  solution  may  be  employed.  Should  the  infection  be 
upon  the  conjunctiva,  this  course  cannot  be  followed.  The  parts  may  be  bathed 
with  strong  bichloride  solution,  care  being  taken  to  wash  out  the  excess. 

Malignant  (Edema. — The  l}acillus  which  causes  this  form  of  rapid  gangrene 
resembles  the  anthrax  bacillus.  It  is  motile,  anaerobic,  and  reproduces  itself  by 
sporulation,   the  spore  being  near  the  center- of  the  organism    (Fig.   796).     Its 


•?■%<• 


Pig.  795. — Bacillus  of  glanders.  Pure  cultures 
upon  glycerin-agar,  teased  specimen 
stained  with  carbolic-fuchsin.  X  100. 
(Frankel  and  Pfeiffer.) 


Fig.  796. — A,  bacillus  of  malignant  oedema.     B,  spore  formation.      (After  Tillmanns.) 


habitat  is  in  fertile  soil,  foul  water,  and  decomposing  matter.  It  seems  to  possess 
the  property  of  producing  rapid  decomposition  of  the  tissues  with  which  it  comes 
in  contact.  The  disease  is  rare  in  man.  It  is  possible  that  the  rapid  gangrenous 
processes,  of  which  many  epidemics  were  reported  in  military  hospitals  (hospital 
gangrene),  were  due  to  the  presence  of  this  then  unrecognized  micro-organism> 


THE   SUP.GICAL   DISEASES  755 

Modern  antisepsis  has  practically  eliminated  this  disease  from  the  category  of  sur- 
gical infections. 

Foot  and  mouth  disease,  so  named  from  the  vesicular  eruption  found  in  the 
mouths  or  in  the  clefts  between  the  hoofs  in  animals,  is  an  acute  infectious  disease 
of  rare  occurrence,  transmitted  very  occasionally  to  man  from  domestic  animals, 
especially  cows,  sheep,  and  hogs.  The  symptoms  as  given  by  Tillmanns  are  stoma- 
titis, gastro-enteritis  with  fever,  and  a  vesicular  eruption  scattered  over  the  body. 
As  a  rule,  the  disease  is  not  fatal  in  adults,  although  children  of  low  vitality 
succumb  to  it. 

The  treatment  is  chiefly  local,  and  does  not  differ  from  that  recommended  in 
glanders. 

Tuberculosis  is  an  infectious  inflammation  of  low  grade,  caused  by  the  hacillus 
tuberculosis  (Fig.  797).  It  is  characterized  by  the  formation  of  nodules  (tuber- 
cles) which  never  suppurate  unless  there  is  a  mixed  infection  with  pyogenic  bac- 
teria. In  sixrgical  practice  the  lymphatic  glands,  bones,  joints,  skin,  and  mucous 
surface  are  the  principal  lesions.  This  specific  organism  was  discovered  by  Eobert 
Koch  in  188?.     It  varies  in  length  from  1.5  /ti  to  3.5  /t  and  0.2  jx  in  breadth,  and 

is  slightly  curvilinear  in  shape,  with 
rounded  ends.     It  is  non-motile,  does 


1, 


Tig    797 — lubercle  bacilli  (lung)       X  700  Fig.  798. — Giant  cell  with  tubercle  bacilli. 

(Koch.)  X  700.      (Koch.) 

not  form  in  chains,  although  it  is  frequently  observed  in  pairs  or  bundles.  It  multi- 
plies by  sporulation,  a  single  rod  containing  at  times  as  many  as  six  spores.  It 
is  aerobic,  but  can  exist  without  oxygen.  In  the  giant  cells  of  the  tuberculous 
process  it  is  found  in  lai'ge  numbers,  usually  in  the  periphery  of  these  bodies 
(Fig.  798).  In  tubercular  nodules  or  foci  which  have  undergone  cheesy  degenera- 
tion the  bacillus  is  rarely  seen,  but  the  caseous  material  found  in  the  nodules  is  rich 
in  spores  capable  of  causing  infection.  This  organism  may  be  carried  into  the 
tissues  through  an  abrasion  of  the  skin  or  through  the  respiratory  or  alimentary 
tracts.  The  chief  source  of  infection  is  the  expectorated  matter  from  individuals 
who  are  afflicted  with  pulmonary  tuberculosis.  It  retains  its  vitality  in  the  sputum 
which  has  been  dried  for  three  years.  The  dust  about  hotels  and  localities  where 
consumptives  congregate  is  rich  "in  germs.  Cow's  milk  is  a  source  of  infection  of 
great  importance,  as  this  disease  is  exceedingly  prevalent  in  cattle.  The  bacillus 
is  found  not  only  in  the  milk  of  cows  whose  udders  are  diseased,  but  in  those 
affected  with  general  tuberculosis  with  seemingly  healthy  milk-bags.  The  germs 
from  unsterilized  milk  frequently  enter  the  system  through  abrasions  in  the  buccal 
cavity.  From  the  mouth,  pharynx,  and  tonsils  they  find  their  way  into  the 
lymphatic  channels,  and  soon  produce  enlargements  in  the  glands  beneath  the  jaw 
and  in  the  neck  (scrofula).  The  vitality  of  the  bacillus  of  tuberculosis  is  not 
impaired  by  the  action  of  the  gastric  juice,  nor  even  of  the  toxic  products  of 
decomposition. 


756 


THE   SURGICAL   DISEASES 


In  the  tissues  it  produces  a  circaimscribed  inflammation  of  mild  type.  The 
fixed  cells  in  contact  with  the  invading  organisms  undergo  proliferation,  and  thus 
are  formed  the  nodules  or  tubercles.  At  the  center  of  these  nodules  the  bacilli 
first  perish,  while  at  the  periphery  their  proliferation  continues,  and  they  advance 
with  the  process  of  inflammation  toward  the  surrounding  tissues.  Examination 
under  the  microscope  shows  the  nodule  to  be  composed  of  leucocytes,  "  epithelioid," 
and  large  "giant"  cells  all  held  together  in  a  nodular  mass  by  a  delicate  reticu- 
lum. The  aggregation  of  leucocytes  which  wander  through  the  vascular  walls  to 
the  intravascular  spaces  form  the  so-called  "lymphoid"  cells  of  the  tubercular 
process. 

In  certain  instances  the  connective-tissue  proliferation  predominates,  forming 
a  fibrous  tuberculous  nodule,  which  is  grayer  or  more  pearl-like  in  appearance  and 
has  no  well-marked  reticulum. 

The  hyaline  nodule  is  also  occasionally  observed,  the  reticulum  having  under- 
gone a  waxy  degeneration. 

Tubercular  nodules  are  prone  to  undergo  caseation,  the  process  beginning  in 
the  center  and  gradually  involving  the  entire  tulierculous  area.    This  cheesy  matter 

is  composed  of  the  debris  of  all  the  cells  that 
have  undergone  destructive  metamorphosis. 
Occasionally  the  investing  (connective-tis- 
sue) capsule  is  found  to  have  undergone  a 
calcareous  change  in  the  effort  to  confine  the 
infectious  spores. 


Fig.  79Sa. — Bier's  method  for  the  shoul- 
der-joint. ("Journal  American  Med- 
ical Association,"     August  17,  1907.) 


Fig.  7986. — The  same  for  the  elbow.  The  Esmarch  band- 
age has  not  yet  been  applied  below  the  joint.  ("  Jour- 
nal American  Medical  Association,"  August  17,  1907.) 


The  early  removal  by  operation  of  all  infected  lymphatic  glands  is  imperative, 
and  is  easily  accomplished  and  practically  free  from  danger  if  done  before  a  mixed 
infection  has  caused  an  agglutination  of  the  infected  glands  to  the  surrounding 
tissues. 

Prof.  A.  Bier,  of  Berlin  (Journal  American  Medical  Association,  August  17, 
1907)  has  demonstrated  that  the  partial  stagnation  of  the  blood  current  in  any 
part  of  the  body  affected  by  an  inflammatory  process  will  result  in  the  gradual 
disappearance  of  the  sj^mptoms  of  infection,  with  complete  recovery  in  a  certain 
proportion  of  cases.  Thus,  in  tuberculous  osteo-arthritis  at  the  shoulder,  Esmarch's 
or  Martin's  elastic  bandage  is  applied  from  the  finger-tips  to  about  the  deltoid 
insertion.    This  should  not  be  tight  enough  to  arrest  the  radial  pulsation.    A  piece 


THE   SrRGICAL   DISEASES  757 

of  rabber  tubing  is  next  api^lied  at  the  axilla  and  over  the  collar  bone  behind 
the  acromion  process,  vrheie  it  is  drawn  s\iffieiently  tight  to  retard  but  not  com- 
pletely arrest  the  return  circulation  in  the  veins  in  'the  area  of  inflammation.  The 
arrangement  for  holding  this  constricting  tube  in  place  is  shown  in  Fig.  798a. 
While  maintaining  the  venous  engorgement  of  the  tissues  between  the  tsvo  band- 
ages, the  pressure  should  be  so  adjusted  as  not  to  cause  marked  discomfort.  It 
may  be  slight  at  first  and  gradually  increased  tmtil  the  proper  degree  of  "stag- 
nant hvperajmia  "'  is  secured.  The  parts  beyond  the  tournicpet  should  never  be 
permitted  to  become  cold  or  clammy.  The  bandage  shotdd  remain  in  position 
from  three  to  four  hours.  It  may  at  times  be  worn  without  marked  discomfort 
for  as  much  as  eleven  continuous  hours.  After  removal  the  part  which  has  been 
subjected  to  compression  by  the  Esmareh  bandage  shotdd  be  thoroughly  massaged 
in  order  to  guard  against  pressure  atrophy  (Willy  Meyer).  The  treatment  may 
be  continued  for  sis  months  or  a  3'ear,  or  longer  if  necessary.  The  method  of 
applying  the  Esmareh  bandage  as  a  constrictor  in  lesions  at  the  elbow-joint  or 
below  this  is  sho-mi  in  Fig.  79Sb.  The  method  is  also  highly  recommended  in 
inflammatory  processes  other  than  those  of  tuberculous  origin. 

The  other  forms  of  tuberculosis  which  come  within  the  domain  of  surgery  will 
be  considered  in  the  chapters  which  treat  of  the  different  regions  of  the  body 
involved. 

Leprosy,  a  disease  caused  by  the  bacillus  leprje,  discovered  by  Hansen  in  1879, 
is  exceedingly  rare  in  the  United  States.  It  belongs  to  the  domain  of  dermatology 
rather  than  of  surgery. 

XoTE. — A  consideration  of  the  bacillus  of  typhoid  fever  does  not  come  within  the  domain  of 
surgical  pathologj',  but  deserves  mention  from  the  fact  that  it  has  been  met  with  in  abscesses, 
which,  however,  were  probably  due  to  mixed  infection  during  the  process  of  tj^jhoid  fever.  The 
thermal  death  point  of  this  organism  is  56°  C.  (1.38.8°  F.)  in  streaming  steam. 

DisiXFECTiox  OF  ExcRETA. — Under  certain  conditions,  the  surgeon  may  be  called  upon  to 
ad\ise  in  the  disposition  of  infectious  excreta:  the  discharges  of  dysenterj',  tuberculosis,  diphtheria, 
yellow  fever,  scarlet  fever,  tj-phus  and  tj-phoid  patients;  the  vomited  matter  in  cholera,  diphtheria, 
yellow  fever,  scarlet  fever:  the  sputum  in  tuberculosis,  diphtheria,  scarlet  fever,  and  pneumonia; 
and  the  urine  of  all  patients  -nith  infectious  diseases.  The  most  efficacious  method  is  by  burning, 
and  if  this  cannot  be  done,  the  next  best  thing  to  be  done  is  to  pour  boiling  water,  in  quantity 
five  or  ten  times  greater,  upon  the  material  to  be  disinfected.  Chloride  of  lime  of  the  best  quality 
(which  shoidd  jield  twenty-five  per  cent  of  available  chlorine  and  which  costs  about  one  cent  a 
gallon)  is  an  excellent  disinfectant.  Distilled  or  pure  water  (six  oimces  to  one  gallon  of  water 
makes  a  proper  solution).  One  quart  is  necessarj'  to  disinfect  each  rectal  discharge.  Expectorated 
matter  shoiild  be  discharged  into  a  vessel  filled  with  this  solution. 


CHAPTEE    XXXYII 

THE    VEiSrEEEAL    DISEASES:    URETHKITIS — SYPHILIS 

Urethritis — inflammation  of  the  urethra — may  be  specific  and  non-specific. 
Specific  urethritis  (gonorrhcea)  is  a  violently  contagious  disease  affecting  primarily 
the  urethra  in  the  male  and  the  urethra  and  vagina  in  the  female.  It  occasionally 
involves  the  rectum.  From  these  points  of  initial  infection  the  active  organisms, 
reenforced  by  other  isogenic  bacteria  may  invade  the  glandular  apparatus  con- 
nected with  the  prostate,  vesiculse  seminales,  vasa  deferentia,  testicles,  bladder, 
ureters,  and  pelves  of  the  kidneys.  In  the  female,  it  may  spread  to  the  glandular 
apparatus  of  the  \Tilva,  the  cervix,  uterus,  the  Fallopian  tubes,  and  peritonffium. 
It  may  be  also  conveyed  to  other  mucous  membranes.  Upon  the  conjujictiva  it 
establishes  a  rapidly  destructive  inflammation,  occasionally  spreading  along  the 
lachrymal  canal  into  the  nose  and  mouth. 

The  germs  of  specific  urethritis  have  been  found  in  peri-urethral  abscesses,  the 
pus  of  suppurating  buboes,  and  in  lesions  of  the  joints  (gonorrhoeal  rheumatism). 

Gonorrhcea  is  one  of  the  gravest  diseases  which  afilict  the  human  family.  When 
it  invades  the  deep  urethra  in  men  or  the  cervix  and  uterus,  it  is  in  very  many 
instances  incurable.  It  may  lie  dormant  for  months  or  years,  springing  up  seem- 
ingly without  cause  and  carrying  with  its  recurrence  the  power  of  infection.  The 
blindness  of  the  new-born  and  fully  eighty  per  cent  of  the  operations  done  upon 
women  for  inflammatory  lesions  of  the  pelvic  organs  are  due  to  this  malady,  while 
in  men,  its  effects,  immediate  and  remote,  are  equally  disastrous.  Such  is  the 
insidiousness  and  so  terrible  are  the  consequences  of  this  infection  that  no  one 
who  has  had  gonorrhcea  should  consent  to  the  sexual  relation  without  the  verdict 
of  an  expert  that  after  a  most  careful  test  gonococci  are  no  longer  present. 

The  germ  of  urethritis  (gonococcus)  was  discovered  by  Neisser  in  1879.  It 
is  from  0.8  ju.  to  1.6  ft  (a  micromillimetre  is  agooo  of  ^^"^  inch)  in  length  and 
0.6  fjL  to  0.8  fi.  in  width,     '\^^len  single  it  is  kidney-  or  bean-shaped,  but  it  appears 


*30 


Fig.  799. — Pure  gonococci,  free  and  within  the 
pus  and  epitheUal  cells. 


Fig.  SOO. — Pseudo-gonococcus   in 
cell  and  free. 


epithelial 


almost  always  as  a  diplococcus,  two  of  the  bean-shaped  bodies  adhering  with  their 
concave  surfaces  toward  each  other  (Fig.  799).  Gonococci  are  found  free  in  gonor- 
rhoeal pus  and  in  large  numbers  within  the  pus  corpuscles,  never  within  the  nucleus 
of  the  cell.    They  are  also  found  in  the  epithelial  cells  of  the  urethral  discharge. 

758 


THE   VENEREAL   DISEASES 


759 


In  the  urethra  there  are  also  found:  (1)  the  smegma  hacilhis,  which  requires 
c'areful  stucty  to  differentiate  it  from  the  bacilhis  tuberculosis;  (3)  pseudo-gono- 
coecus,  found  at  times  in  the  cast-off  epithelia  and  also  within  the  pus  corpuscles 
of   a   non-specific    inflammation    (Fig. 

800);  (3)  the  staphylococcus  pjj'ogenes  '.,-•-.. 

aureus;    and     (4)     the    streptococcus  ;:■,;:'■:•., 

pyogenes  (Figs.  801-802). 

■  ■ .  ■  »I*V  '  ■  „..■•. 


-a 


^-- 


-  ■■??•. 


Fig.  801. — a,  b,  d,  Smegma  bacilli,  which  may  be 
mistaken  for  tubercle  bacilli  ;  c,  /,  diplococci 
in  small  hyaline  cell — pseudo-gonococcus  ; 
e,  staphylococcus  pyogenes  aureus. 


Fig.     802.— Strci.iMr,j<'cii,     j.yogenes     i 
hj'aline  epltliclimii  of  urethra. 


large 


Several  species  of  diplococci  so  closety  resemble  Neisser's  gonococcus  in  shape 
and  in  staining  qualities  that  in  making  a  diagnosis  of  specific  urethritis  it  is 
necessary  not  only  to  recognize  the  shoals  of  diplococci  crowding  the  pus  corpus- 
cles, epithelial  cells,  and  floating  free  in  the  discharge,  but  to  associate  these  with 
the  general  and  grosser  symptoms  of  true  gonorrhoea. 

A  simple  and  rapid  method  of  demonstrating  the  gonococcus  of  N'eisser  is  as 
follows :  Place  a  small  drop  of  the  discharge  upon  a  cover-glass  and.  smear  by 
ruljbing  two  cover-glasses  together;  dry  it  by  passing  one  of  the  cover-glasses  with 
pus  side  upward  through  a  spirit  flame  two  or  three  times;  immerse  this  at  once 
in  a  solution  of  methyl  blue;  wash  off  the  excess  of  coloring  matter  by  holding  it 
under  clear  running  water  or  by  dipping  the  glass  several  times  into  clear  water; 
dry  the  stained  pus  well  by  pressing  with  blotting  paper;  then  cover  it  with  a 
small  drop  of  cedar  oil ;  put  on  a  thin  cover-glass  and  examine  with  a  lens  mag- 
nifying from  700  to  1000  diameters.  The  fieculiar  double  bean-shaped  arrange- 
ment of  the  diplococci  will  be  seen  within  the  protoplasm  of  the  pus  corpuscle  and 
epithelium.  "^ 

When  the  discharge  is  scanty  it  may  be  obtained  on  a  film  of  cotton  wrapped 
about   a  probe  and  introduced  into   the  urethra.     When   the   microscope   is   not 

'  Gram's  method,  which  may  be  used  in  doubtful  cases,  is  more  complicated.  To  fresh  aniline 
water  (aniline  oil  shaken  well  with  water  and  filtered  through  moistened  filter  paper)  a  concen- 
trated alcoholic  solution  of  gentian  violet  is  added,  drop  by  drop,  up  to  the  point  of  saturation 
• — i.  e.,  until  the  liquid  loses  its  transparency.  The  cover-glass  prepared  as  above  is  allowed  to 
float  on  this  solution  for  ten  minutes.  It  is  then  washed  with  water,  and  placed  for  five  minutes 
in  a  solution  of  iodine  (one  part),  iodide  of  potassium  (two  parts),  distilled  water  (three  hundred 
parts),  and  from  there  put  in  absolute  alcohol,  where  it  remains  until  no  more  color  is  extracted. 
After  a  renewed  washing,  the  preparation  is  subjected  for  half  a  minute  to  a  second  process  of 
staining  in  a  weak  (light-brown)  watery  solution  of  Bismarck  brown  or  vesuvine,  washed  again 
with  water,  and  examined  as  before  in  water  or  Canada  balsam.  If  a  preparation  treated  in  this 
manner  shows  blue  diplococci,  it  is  sure  that  they  are  not  gonococci;  but  in  case  of  brown  diplo- 
cocci, no  absolute  certainty  is  reached.  For  the  bacterioscopic  examination  of  gonorrhoeal  or 
urethral  discharges  a  good  microscope  with  Abbe's  condenser  and  highly  magnifying  lens  is  needed. 
Dry  objective  lenses  are  not  to  be  recommended  except  Zeiss'  new  apochromatic  system,  while 
a  one-twelfth-inch  homogeneous  immersion  lens  and  an  ocular  No.  2  and  No.  3  will  answer  the 
purpose  very  well.     (Lustgarten.) 


760  THE   VENEREAL   DISEASES 

employed  tlie  diagnosis  will  be  emphasized  by  the  history  of  exposure,  the  time 
elapsing  between  contact  and  the  appearance  of  the  discharge,  the  peculiar,  irri- 
tating character  of  the  discharge,  and  the  progi'essive  increase  of  the  same  during 
the  first  five  or  six  days. 

Symptoms. — When  the  virus  is  brought  in  contact  with  the  mucous  surface 
of  the  urethra,  the  period  of  time  which  elapses  before  local  symptoms  of  inflam- 
mation appear  varies  greatly  in  differed  individuals,  and  even  in  the  same  indi- 
vidual in  different  inoculations.  It  is  very  probaljle  that  the  condition  of  the 
mucous  membrane  at  the  time  of  contact,  as  well  as  the  variations  in  the  normal 
resistance  of  the  patient's  tissues,  have  a  great  deal  to  do  with  the  rapid  progress 
of  the  inflammation,  and  it  may  be  that  the  virus  in  some  instances  is  more  in- 
tensely infective  than  in  others.  Thus  the  period  of  incubation  varies  from  a  few 
hours  to  several  days,  and  in  very  rare  instances  as  much  as  two  weeks  have  elapsed 
between  the  contact  and  the  recognition  of  the  inflammatory  process.  The  limit, 
however,  between  twenty-four  hours  and  three  days  will  include  the  large  majority 
of  cases  of  specific  urethritis.  Usually  the  earliest  syniptom  is  a  burning  sensation 
at  the  meatus,  which  is  -more  severe  as  the  urine  is  escaping.  The  lips  of  the 
meatus  soon  become  swollen,  usually  everted,  j)rominent,  and  red.  When  carefully 
separated,  a  thin  film  of  muco-pus  will  be  seen  coating  the  mucous  membrane. 
The  first  stage  of  the  disease  may  be  considered  as  beginning  at  the  moment  of 
contact,  and  ending  with  the  first  appearance  of  suppuration.  The  average  dura- 
tion is  from  two  to  ten  days.  From  this  period,  in  neglected  cases,  the  inflamma- 
tory symptoms  increase  for  from  four  days  to  as  much  as  two  weeks.  The  quantity 
of  pus  discharged  varies  from  a  few  drops  to  several  drams  in  the  twenty-four 
hours.  It  is  increased  by  exercise,  by  unnecessary  exposure  to  cold  and  wet,  the 
use  of  alcoholic  stimiilants,  any  form  of  dissipation,  and  improper  diet.  The 
color  of  the  discharge  varies  from  the  bluish-white  hue  of  the  first  few  drops  to 
the  yellow  and  yellowislvgreen  tinge  of  that  discharged  during  the  height  of  the 
inflammatory  process.  In  some  instances  it  becomes  stained  with  blood  as  a  result 
of  rupture  of  the  capillaries  in  the  engorged  niTicous  membrane. 

The  second  stage,  that  of  increasing  inflammation  and  suppuration  (in  cases 
not  treated),  lasts  about  twelve  days.  It  is  followed  by  the  third  stage,  that  of 
decreasing  inflammation,  the  duration  of  which  is  from  three  to  six  weeks.  In 
addition  to  the  purulent  discharge  and  the  jDain  which  characterizes  the  second 
stage  of  the  disease,  there  is  a  diminution  in  the  size  of  the  stream  of  urine,  due 
to  the  swollen  and  puffy  condition  of  the  mucous  membrane  of  the  urethra.  In 
the  milder  forms  of  gonorrhoea  there  are  no  other  s^^mptoms  present  in  the  second 
stage.  In  many  neglected  cases,  however,  the  inflammatory  process  extends  into 
the  membranous  and  prostatic  urethra,  thence  along  the  seminal  ducts,  oftentimes 
into  the  bladder,  epididymis,  and  testicle,  producing  serious  consequences.  In  the 
female  it  may  produce  endometritis  and  salpingitis,  resulting  either  from  infection 
of  the  specific  germ  or  from  a  mixed  infection  with  other  pyogenic  organisms, 
which  find  their  way  into  the  Fallopian  tubes,  causing  abscesses,  producing  sterility 
in  the  vast  majority  of  cases,  and  ultimately  leading  to  the  necessity  of  surgical 
interference.  In  males,  infiltration  of  the  vascular  erectile  tissue  of  the  corpus 
spongiosum  occurs  in  a  varied  degree,  and  occasionally  the  exudation  extends  into 
the  corpora  cavernosa.  A  more  frequent  complication  of  gonorrhoea  is  inflamma- 
tion of  the  glans  penis  (balanitis)  and  of  the  prepuce  (posthitis),  due  not  only 
to  mechanical  irritation  of  the  part,  but  to  direct  infection.  As  a  result  of  such 
extensive  inflammation,  the  penis  is  liable  to  various  deformities,  painful  in  an 
extreme  degree,  and  not  without  danger  to  its  integrity.  CJiordee,  or  bowing  of 
the  organ,  is  a  common  symptom.  It  becomes  in  part  or  wholly  erect,  and,  on 
account  of  the  infiltration  of  the  vascular  spaces  of  the  spongiosum  with  the 
embryonic  inflammatory  tissue,  it  fails  to  expand  with  the  corpora  cavernosa. 

Pathology. — Strictly  speaking,  the  morbid  process  is  an  inflammation  of  the 
mucous  membrane  of  the  urethra  and  the  submucous  connective  tissue  with  or 
witliout  extension  to  other  organs.  It  commences  at  the  meatus  and  travels  back- 
ward. The  epithelium  is  swollen,  there  is  marked  hyperaemia  of  the  submucous 
tissue,  with  the  escape  of  leucocytes,  the  production  of  pus,  and  the  formation  of 


THE   \-EXERE.\L   DISE.\SES  761 

tlie  eomnion  embrTonic  tissue  of  inflammation.  In  milder  cases  the  products  of 
inflammation  imdergo  retrogressive  changes  and  are  absorbed.  Tvhile  in  other  in- 
stances connective-tissue  development  is  precipitated,  ending  in  cicatrization  and 
the  formation  of  stricture.  The  organic  elements  of  gonorrhoeal  pus  are  leucocytes, 
embr3"onie  cells,  epithelia,  and  blood  corpuscles. 

In  a  certain  proportion  of  cases  the  virus  of  gonorrhcea  becomes  absorbed  and 
metastasis  occurs  in  the  joints,  producing  also  endocarditis  at  times,  the  gonococcus 
being  found  in  these  secondary  lesions  as  in  other  metastatic  abscesses. 

Treatment. — It  is  essential  to  begin  treatment  at  the  earliest  possible  moment, 
and  it  is  a  Tvise  precaution  to  consider  every  case  as  specific  or  virulent  until  its 
character  can  be  determined.  Although  difficult  to  aeltieve,  the  first  aim  is  to 
prevent  the  gonococcus  from  reaching  the  deep  urethra.  In  rare  instances  it  may 
be  possible  to  accomplish  this  by  Lyons  method,^  especially  when  only  a  few  hours 
have  elapsed  from  the  date  of  contact. 

After  the  patient  has  urinated  for  the  purpose  of  cleansing  the  canal,  and  is 
in  the  recumbent  posture,  the  operator  injects  into  the  meatus  with  an  ordinary 
funnel-pointed  rubber  syringe  one  dram  of  a  four-per-cent  solution  of  nitrate 
of  silver.  This  is  held  in  the  urethra  for  from  two  to  three  minutes  by  the  watch. 
There  is  little  pain  at  the  time  and  not  a  severe  smarting  on  urination  during  the 
next  twenty-four  hours,  at  which  time  the  treatment  is  repeated,  provided  that 
on  careful  examination  of  the  discharge  gonococci  are  found;  if  not,  no  further 
treatment  is  necessary.  A  t^vo-per-cent  solution  should  be  used  for  the  second 
injection,  and  for  a  third  if  gonococci  are  still  present. 

In  these  acute  specific  eases,  especially  in  a  first  attack,  Prof.  Charles  H.  Chet- 
wood  recommends  an  injection  of  a  ten-per-cent  argyrol  solution  which  fills  the 
uretbra.  with  moderate  distention,  and  is  held  in  contact  with  the  mucous  mem- 
brane for  ten  minutes  by  closure  of  the  anterior  urethra.  This  is  used  three  times 
daily  for  from  one  week  to  ten  days.  "When,  tmder  the  influence  of  this  agent, 
the  acute  symptoms  subside,  irrigation  with  jo^jj-o  permanganate  of  potash  for  ten 
minutes,  two  or  three  times  a  day,  is  substituted.  The  irrigator  should  have  an 
elevation  as  high  as  the  head  of  the  patient  standing. 

A  double,  short  glass  pipette,  to  which  is  attached  an  inlet  and  outlet  rubber 
tube,  is  introduced  into  the  first  half  inch  of  the  urethra.  Digital  pressure  is  now 
made  over  the  memliranous  portion  in  order  to  guard  against  deeper  infection. 
As  the  solution  fills  the  urethra  and  is  running  out,  frequently  interrupted  closure 
of  the  outlet  tube  should  be  made  in  order  to  distend  the  urethra. 

In  non-specific  or  mild  urethritis  the  argvTol  soltitiou  is  not  employed,  per- 
manganate of  potash  being  used  from  the  commencement  of  the  attack. 

Irrigation  with  the  potash  solution  by  means  of  a  single  soft-rubber  catheter 
with  a  free  opening  at  the  lower  end,  which  is  carried  down  as  far  as  the  deep 
urethra,  may  be  substituted.  A  continuous  flow  from  behind,  forward,  can  thus 
be  secured,  and  hyperdistention  is  effected  by  compression  of  the  anterior  part  of 
the  urethra. 

With  any  suggestion  of  involvement  of  the  membranous  and  prostatic  urethra 
the  argyrol  solution  should  be  carried  into  this  portion  of  the  urethra  by  kneading 
or  milking,  or  by  the  catheter. 

In  gonorrhcea  in  the  female,  the  treatment  should  be  applied  to  the  vagina  as 
well  as  the  urethra. 

The  patient  should  be  advised  as  to  the  necessity  of  strict  antisepsis  in  order 
to  prevent  the  inoculation  of  the  conjunctiva.  Disinfection  of  the  hands  with  a 
1-500  mercuric-chloride  solution  is  of  great  value,  and  all  instruments  and  mate- 
rial infected  should  be  thoroughly  boiled. 

An  important  adjunct  in  treatment  is  rest,  regulation  of  diet  and  of  the  man- 
ner of  living.  The  diet  should  be  simple  and  nutritious,  and  all  stimulating 
beverages,  such  as  alcohol,  coffee,  and  tea,  avoided.  The  bowels  should  be  kept 
open  daily.  In  the  first  week  of  this  disease  citrate  of  potash,  twenty  grains,  four 
or  five  times  a  day.  decreases  the  irritating  effect  of  the  urine  by  its  diuretic 
effects.  The  hip  bath  in  warm  water  every  night  and  morning  not  only  insures 
'  "X.  y.  Medical  Record,"  vol.  xl\-ii,  p.  549. 


762  THE   VENEREAL   DISEASES 

a  degree  of  cleanliness,  but  is  of  value  as  an  antiphlogistic.  The  free  discharge 
of  pus  from  the  urethra,  vagina,  and  prepuce  is  essential.  An  absorbent  dressing 
or  bag  of  oil  silk  or  rubber  tissue  made  to  fit  without  pressure  may  be  held  in 
place  by  strings  fastened  to  a  belt  around  the  waist.  Absorbent  cotton  is  useful 
in  taking  up  the  discharge. 

Chronic  or  recurring  urethritis  is  one  of  the  most  distressing  of  the  genito- 
urinary diseases.  Gonococci  or  other  pathogenic  organisms  once  lodged  in  the 
follicles  of  the  prostate,  or  in  the  mucous  and  submucous  tissues  of  the  deep 
urethra  or  vesiculs  seminales,  are  practically  beyond  the  reach  of  local  applica- 
tions. While  these  should  be  thoroughly  employed  for  the  destruction  of  such 
organisms  as  may  be  reached,  the  chief  reliance  must  be  in  building  up  the  patient's 
resistance  and  aiding  phagocytosis  by  careful  nourishment. 

Balanitis  and  ijosihitis  (inflammations  of  the  glans  and  prepuce)  are  condi- 
tions existing  in  a  varying  degree  in  almost  all  cases  of  specific  urethritis,  the  acrid 
discharge  readily  affecting  the  epithelial  covering  of  these  organs.  When  the  fore- 
skin becomes  swollen,  tense,  and  painful,  the  annoying  condition  of  phimosis  re- 
sults, and  in  some  cases  paraphimosis  ensues,  and  may  require  operative  interfer- 
ence to  prevent  sloughing.  In  phimosis  it  is  often  necessary  to  irrigate  the  glans 
beneath  a'  tight  foreskin  with  the  permanganate  solution,  either  with  a  specially 
constructed  syringe  with  a  delicate  nozzle  or  with  a  common  fountain  syringe. 
If  these  milder  measures  do  not  suffice,  an  incision  through  the  prepuce  along  the 
middle  line  of  the  dorsum  should  be  made  to  expose  the  excoriated  surfaces  or  to 
relieve  tension. 

Non-specific  Urethritis. — This  form  of  urethritis  is  due  to  infection  of  the 
mucous  membrane  of  this  canal  by  pyogenic  organisms  independent  of  the  gono- 
cocci. Traumatism  due  to  external  violence,  or  excessive  sexual  indulgence,  the 
introduction  of  unclean  instruments,  foreign  substances,  calculi,  etc.,  produce  con- 
ditions favorable  for  the  lodgment  and  proliferation  of  pus-making  organisms  and 
the  development  of  a  jjurulent  discharge.  It  is  usually  of  short  duration,  mild 
in  character,  and  involves  only  a  limited  portion  of  the  canal.  The  diagnosis  may 
be  made  from  the  absence  of  the  gonococci  in  large  numbers  and  within  the  pus 
cells  and  epithelia,  as  given  in  specific  urethritis,  and  from  the  absence  of  the 
s3'mptoms  of  a  violent  infection.  The  treatment  is  rest,  the  removal  of  any  cause 
of  irritation,  the  dilution  and  sterilization  of  the  urine,  and  irrigation,  as  in 
gonorrhoea. 

Syphilis  is  an  infectious  disease  affecting  the  nutrition  of  aU  the  tissues.  It 
is  believed  to  be  due  to  the  presence  in  the  blood  of  a  specific  micro-organism,  the 
Spirochete  pallida. 

It  may  be  acquired  or  inherited.  Acquired  syphilis  ensues  when  the  specific 
germ  is  carried  into  the  lymph  or  blood  channels  of  a  human  being.  It  is  believed 
that  an  abrasion  of  the  skin  or  mucous  membrane  is  essential  to  inoculation.  The 
germ  is  conveyed  in  the  fluid  which  transiides  from  the  surface  of  the  initial 
ulcer  (chancre)  and  from  mucous  patches.  The  blood  of  a  syphilitic  patient 
carries  the  poison  if  injected  into  or  inoculated  upon  the  tissues  of  a  non-immune. 
The  same  is  true  of  the  liquid  from  the  cutaneous  lesions  of  the  secondary  stage 
of  syphilis.  It  is  not  admitted  that  the  lesions  of  tertiary  syphilis  are  capable  of 
reproducing  the  disease. 

The  normal  secretions  from  a  syphilitic  subject  will  not  produce  the  disease 
when  unmixed  with  the  discharge  from  mucous  patches  or  the  initial  ulcer.  Milk 
from  a  woman  in  any  stage  of  the  disease  will  not  produce  it  when  injected  into  the 
tissues  or  ingested  as  food. 

Transudation  from  a  fissure  in  the  nipple  of  a  syphilitic  nurse  brought  in  con- 
tact with  an  abrasion  upon  the  lip,  tongue,  or  buccal  wall  of  a  child  will  produce 
this  disease  in  a  non-immune  subject.  On  the  other  hand,  a  syphilitic  child  may 
inoculate  a  healthy  nurse.  It  is  claimed  that  the  pus  from  a  vaccine  pustule  on 
a  sypbilitic  subject  does  not  convey  the  virus,  even  when  the  vaccination  has  been 
successful ;  but  if  blood  be  mingled  with  the  pus,  syphilis  may  result. 

Inoculation  occurs  most  frequently  upon  the  genital  organs,  but  it  may  occur 
on  any  part  of  the  body.     Physicians  are  frequently  inoculated  on  the  finger  in 


THE   VENEREAL   DISEASES  763 

examining  patients,  and  in  like  manner  they  may  transfer  the  virus  to  others. 
If  rubber  gloves  were  worn,  this  accident  could  not  occur.  Dentists  and  barbers 
may  also  convey  the  virus  from  a  syphilitic  to  a  non-immune  subject.  The  germs 
from  an  ulcer  on  the  lip  or  of  mucous  patches,  lodged  upon  a  drinking  vessel, 
may  inoculate  an  abrasion  on  the  lip  of  a  non-syphilitie  subject. 

The  clinical  history  of  a  typical  case  of  acquired  syphilis  which  runs  its  course 
may  be  divided  in  three  stages :  primary,  secondary,  and  tertiary.  In  cases  recog- 
nized in  their  incipiency  and  properly  treated,  the  later  manifestations  may  be 
entirely  eliminated. 

The  primary  stage  includes:  (1)  the  entrance  of  the  specific  organism;  (2)  the 
ulcer;   (3)  local  lymphangitis  and  adenitis. 

To  the  second  stage  belong  the  cutaneous  eruptions,  mucous  patches,  fever, 
arteritis,  condylomata,  alopecia,  iritis,  and  general  adenitis.  In  the  tertiary  stage 
.  the  pathological  changes  are  confined  chiefly  to  the  arteries,  viscera,  bones,  the 
integument,  and  the  .subcutaneous  and  submucous  connective  tissue.  This  is  the 
period  of  gummy  tumors,  connective-tissue  formations,  arterial  occlusion,  and  deep- 
seated  ulcers  of  the  skin  and  mucous  membrane. 

The  first  stage  lasts  from  sis  to  nine  weeks.  Secondary  symptoms  may,  how- 
ever, appear  at  the  fifth  or  sixth  week  from  the  date  of  the  inoculation.  In  rare 
instances  they  may  be  delayed  from  three  to  six  months. 

The  second  stage  lasts  generally  from  the  fifth  or  sixth  week  after  the  inocu- 
lation to  about  the  end  of  the  first  year. 

The  tertiary  stage  begins  at  the  end  of  the  preceding  stage,  and  may  last 
indefinitely. 

When  the  specific  germs  are  lodged  in  an  abrasion  the  changes  while  absorption 
is  taking  place  may  be  so  slight  as  not  to  attract  attention.  If,  as  is  usually  the 
case,  pyogenic  organisms  also  lodge  in  this  abrasion,  a  mixed  infection  takes  place, 
causing  an  ulcer  more  or  less  phagedenic  in  character. 

Absorption  takes  place  chiefly  through  the  lymphatic  channels.  There  is  usually 
a  period  of  three  weeks  from  the  lodgment  of  the  virus  until  the  local  inflamma- 
tory process  is  recognized,  but  before  this  is  seen  the  poison  has  already  passed 
into  the  lymph  channels,  to  be  temporarily  arrested  in  the  nearest  group  of  glands. 
From  the  inoculation  to  the  appearance  of  the  ulcer  the  time  is  about  three  weeks, 
never  less  than  ten  days;  occasionally  it  is  delayed  as  many  weeks.  The  duration 
of  the  sore  varies  from  two  to  ten  weeks,  at  times  longer.  It  often  begins  as  a 
small  papule,  from  the  covering  of  which  a  clear  seruni  escapes,  or  from  the 
beginning  it  may  exist  as  an  erosion.  There  is  usually  one,  although  there  may 
be  several  points  inoculated  simultaneously. 

An  uncomplicated  initial  lesion  does  not  tend  to  ulcerate.  It  is  usually  cir- 
cular or  oval  in  outline,  is  shallow,  increasing  gradually  in  depth  from  the  periph- 
ery toward  the  center,  and  its  surface  is  covered  with  a  yellow  serous  transudation. 

Grasped  between  the  thumb  and  finger,  it  is  found  to  be  indurated  but  not 
painful.  The  induration  is  closely  limited  to  the  sore,  and  terminates  rather 
abruptly,  not  fading  off  gradually  in  a  wide  infiltration  of  the  skin. 

When  a  syphilitic  ulcer  becomes  infected  with  pyogenic  bacteria  it  loses  its 
specific  character  and  becomes  in  appearance  and  behavior  a  phagedenic  or  soft 
chancre. 

If  the  sore  is  well  on  one  side  of  the  penis  or  vulva,  the  glands  of  that  side 
are  usually  first  affected.  When  situated  in  the  median  line,  or  if  ulcers  exist  on 
both  sides,  the  adenitis  is  apt  to  be  bilateral.  In  very .  exceptional  cases  ulcer  of 
one  side  is  followed  by  unilateral  adenitis  on  the  opposite  side  of  the  body.  Dating 
from  the  appearance  of  the  sore,  from  eight  to  fourteen  days  usually  elapse  before 
enlargement  of  the  inguinal  glands  is  noticed.  Less  frequently,  three  or  four 
weeks  intervene. 

From  one  to  seven  distinct  glandular  nodules  may  be  felt.  They  are  hard,  yet 
slightly  elastic  to  the  touch,  not  painful  under  ordinary  pressure,  and  freely 
movable  beneath  the  skin.  They  vary  in  size  from  those  that  are  so  small  as 
scarcely  to  be  recognized  up  to  half  an  inch  or  more  in  diameter.  There  is  no 
periadenitis,   and  unless   an   acute   or  phagedenic  inflammatory  process  is   super- 


764  THE   VENEREAL   DISEASES 

added,  the  glands  do  not  become  matted  together  in  one  hard,  painful  lump,  nor 
does  the  integument  become  red  and  sensitive,  as  in  the  adenitis  of  phagedenic 
ulcer  or  gonorrhoea.  The  primary  adenitis  continues  into  the  second  stage,  in  which 
induration  of  the  glands  is  general.  When  the  ulcer  is  situated  upon  the  lips, 
tongue,  or  mouth,  the  submaxillary  plexus  becomes  enlarged.  Adenitis  of  the 
epitrochlear  and  axillary  glands  follows  inoculation  upon  the  fingers,  hand,  or 
forearm. 

Second  Stage. — In  this  stage  cutaneous  and  mucous  lesions  occur  with  falling 
of  the  hair,  fever,  headache,  arteritis,  lymphangitis,  adenitis,  iritis,  and  osteitis. 

The  skin  lesions  (syphilides)  may  be  macular,  papular,  vesicular,  pustular, 
and  tubercular. 

The  macular  syphilide  appears  as  an  indistinct  spot  or  stain,  not  elevated,  vary- 
ing from  a  light  red  to  a  slate  or  copper  color.  It  is  frequently  seen  at  the  end 
of  the  first  stage,  about  the  sixth  or  seventh  week  after  the  ulcer  appears,  but  • 
may  come  later.  The  macular  are  usually  first  observed  upon  the  abdomen,  and 
may  spread  over  the  entire  body.  Thev  vary  in  size  from  a  pin-head  to  round  or 
oval  spots  a  half  inch  or  more  in  diameter. 

The  papular  syphilide  occurs  in  several  forms,  which  may  be  present  in  the 
secondary  or  tertiary  period.  Not  only  the  skin,  but  the  mucous  surfaces  may 
be  affected,  and  the  papulae  may  be  preceded  or  accompanied  by  maculte.  Some 
may  be  small  and  pointed,  others  broader  at  the  base  and  flat  on  top,  like  a  trun- 
cated cone.  Upon  mucous  surfaces  the  papular  character  of  the  eruption  may  be 
observed  if  seen  early,  but  on  account  of  the  moisture  the  papules  soon  disappear, 
leaving  mucous  patches  which  may  be  elevated  or  depressed.  When  recent,  these 
patches  are  red  in  color,  but  later  become  covered  with  a  whitish-gray  film. 

The  papular  syphilide,  which  occurs  near  the  junction  of  the  skin  and  mucous 
surfaces,  as  those  below,  the  mammary  glands  in  women,  and  between  the  thighs 
and  gluteal  regions  in  either  sex,  often  as  result  of  uncleanliness  and  irritation, 
becomes  developed  into  a  papillary  or  watery  growth  known  as  condylomata. 

The  papular  eruption  of  syphilis  may  cover  the  entire  body,  and  is  often  well 
marked  upon  the  palms  and  soles,  while  at  times  the  trunk  alone  is  occupied,  the 
face,  hands,  and  feet  escaping.  They  are  well  defined,  vary  in  size,  and  are  darker 
in  color  than  the  macuhe.  The  eruption  disappears  by  absorption  of  the  cells 
which  have  infiltrated  the  papillffi  and  corium,  and  this  may  occur  with  or  without 
desiccation.  The  scaling  syphilide,  or  psoriasis  syphilitica,  is  at  times  with  dif- 
ficulty differentiated  from  true  psoriasis,  especially  when  the  inoculation  is  denied. 

The  vesicular  syphilide  is  peculiar  to  the  second  stage,  and  is  seldom  observed. 
The  vesicles  may  be  small,  pointed,  and  gathered  in  clusters  as  in  herpes,  or  scat- 
tered at  various  intervals  over  the  body.  Commencing  as  vesicles,  they  sometimes 
become  jDustules,  which,  as  evaporation  occurs,  are  covered  with  small  crusts  or 
scabs. 

The  pustular  syphilide,  while  almost  always  associated  with  the  hair  follicles, 
may  be  met  with  on  all  parts  of  the  body.  It  is  most  common  in  the  secondary 
and  not  infrequently  seen  in  the  tertiary  period.  In  the  later  manifestations 
they  have  wide  bases,  and  may  spread  extensively. 

Scabbing,  with  underlying  ulceration,  is  the  common  history  of  all  pustular 
syphilides,  although  extensive  molecular  death  of  tissue  is  less  apt  to  occur  in  the 
secondary  than  in  the  tertiary  stage.  The  color  of  the  crusts  varies  from  black 
to  a  brownish-copper  color.  If  the  scab  is  removed  the  walls  of  the  ulcer  will  be 
seen  to  be  precipitate  and  curvilinear  in  outline,  while  the  floor  is  covered  with  a 
varying  amount  of  serum  and  detritus. 

The  tubercular  syphilide  is  so  rarely  a  lesion  of  secondary  syphilis  that  it  will 
be  described  with  the  symptoms  of  the  third  stage. 

It  is  exceedingly  rare  to  find  all  of  the  foregoing  syphilides  in  any  one  indi- 
vidual. The  macular  and  papular  frequently  come  together,  while  the  pustular 
form  usually  occurs  alone. 

Alopecia  occurs  in  varying  degree  in  most  eases  of  well-marked  syphilis. 
Though  observed  chiefly  in  the  scalp  and  beard,  all  the  hairy  portions  of  the 
body  may  be  involved.     Except  in  the  case  of  the  pustular  syphilide,  the  hair 


THE   VEXEREAL   DISEASES  765 

follicles  are  rarely  destroyed,  so  that  as  the  violence  of  the  attack  is  diminished 
the  hairs  are  reproduced.  Falling  of  the  hair  from  general  seborrhoea  is  one  of  the 
later  manifestations  of  syphilis. 

Fever. — Eleyation  of  temperature  occurs  in  the  second  stage  of  syphilis  in  a 
large  proportion  of  cases.  It  may  be  so  mild  as  not  to  be  obseryed.  but  as  a 
rule  the  thermometer  will  register  from  one  to  three  degrees  above  the  normal. 
Febrile  movement  usually  begins  when  the  virus  has  passed  through  the  first  net- 
work of  lymphatics.  It  may  precede  the  eruption  or  occur  with  it,  and  in  general 
continues  after  the  eruption  disappears. 

Headache,  usually  referred  to  the  frontal  rv;gion.  at  times  to  the  vertex  or  base, 
occurs  during  the  period  of  fever,  and  is  generally  proportionate  to  the  intensity 
of  the  febrile  movement. 

Arteritis,  lymphangitis,  and  general  adenitis  occur  in  the  secondary  stage  and 
in  neglected  cases,  continue  into  the  third  stage.  Iritis  is  not  uncommon  in  sec- 
ondary syphilis,  is  usitally  unilateral,  and  is  recognized  by  immobility  of  the  iris, 
photophobia,  and  by  the  red  injection  of  the  membrane. 

Pathological  changes  in  the  bones  do  not  occur,  as  a  rule,  in  the  early  stages 
of  sypliilis.  Pain,  mild  in  character,  is  present  in  some  cases  in  the  second  stage, 
but  lesions  of  the  osseous  structures  belong  to  the  last  stage  of  this  disease. 

Third  Stage. — The  lesions  of  tertiary  syphilis  rarely  manifest  themselves  earlier 
than  the  second  year.  They  may  continue  for  a  while  and  disappear,  and  in 
neglected  cases  return  at  varying  intervals  during  the  life  of  the  individual.  ISTo 
tissue  or  organ  is  exempt  from  the  grave  pathological  changes  induced  by  the 
syphilitic  virus  in  this  stage. 

Shin. — Xodules  resulting  from  cell  proliferation  and  accumulation  in  the  deeper 
layers,  and  at  times  in  the  subcutaneous  tissues  (guramata),  appear,  and  after 
existing  for  a  considerable  period,  may  lead  to  molecular  death  of  the  adjacent 
tissues,  or,  failing  in  this,  undergo  fatty  metamorphosis  and  absorption.  The  syph- 
ilitic ulcer  of  this  stage  is  round,  oval,  or  curvilinear,  with  regular  edges,  not 
ragged  or  indented.  When  granular  degeneration  occurs  the  skin  immediately 
over  the  tubercle  has  a  stretched  or  glazed  appearance,  and  is  slightly  discolored. 

A  not  infrecjtient  pustular  cutaneous  lesion  of  the  third  stage  is  kno^™  as  rtipia 
syphilitica.  In  very  rare  instances  a  pustular  syphilide,  similar  in  appearance  and 
with  difficulty  differentiated  from  rupia,  occttrs  as  a  secondary  lesion.  The  rupia 
pustules  are  circular  or  oval  in  shape,  appear  as  slight  elevations  or  blebs,  which 
soon  break  open.  The  seropurulent  contents  ooze  out;  evaporation  and  scabbing 
occur :  these  cnists,  by  reason  of  new  deposits  underneath,  are  gradually  lifted,  and 
give  to  the  scab  a  laminated,  rough,  oyster-shell  appearance.  These  crusts  are  dark 
brown  or  slightly  greenish  in  color.  When  the  late  cutaneous  lesions  of  syphilis 
attack  the  fingers,  the  nail  or  matrix  is  affected  (paronychia),  causing  a  rough- 
ened condition  of  the  nail  and  a  swollen  matrix,  leading  at  times  to  temporary 
and  occasionally  to  permanent  loss  of  the  nail.  In  like  manner,  permanent  alopecia 
may  occur  from  destrttction  of  the  hair  follicles. 

Xervous  System:  Brain. — Paralysis  is  one  of  the  most  frequent  lesions  of 
tertiary  syphilis.  It  may  be  caused  by  pressure  of  a  gumma  developed  within  the 
brain  substance,  or  upon  the  meninges;  pressure  from  exostoses;  destrttction  of 
brain  cells  by  connective-tissue  hj'perplasia  in  the  neuroglia,  with  consequent  cica- 
trization and  contraction;  and  by  more  or  less  complete  occlusion  of  the  arteries 
(endarteritis  obliterans). 

Hemiplegia,  partial  or  complete,  is  the  rule.  Occasionally  the  center  of  lan- 
guage is  alone  affected.  Dementia  may  ensue  as  the  result  of  softening  or  pres- 
sure, and  epilepsy  may  be  classed  among  the  late  manifestations  of  this  disease. 

Chronic  meningitis  is  an  occasional  s}-mptom  of  late  syphilis.  It  is  accom- 
panied Ijy  headache,  dull  and  persisting  in  character,  impairment  of  intellect,  inter- 
ference with  the  ftmctions  of  one  or  more  of  the  cranial  nerves  by  extension  of 
the  morbid  process,  resulting  at  times  in  ptosis,  strabismus,  or  impairment  of 
vision,  hearing,  taste,  smell,  etc.  The  more  seriotis  cases  progress  gradually  to 
coma  and  death.  There  is  in  all  an  elevation  of  temperature,  loss  or  imijairment 
of  appetite,  and  derangement  of  the  entire  digestive  apparatus. 


766 


THE   VENEREAL   DISEASES 


The  spinal  cord  and  its  membranes  are  less  frequently  attacked, 
more  or  less  complete,  may  ensue,  involving  at  times  the  bladder  and  rectum.  In 
milder  cases  coordination  is  disturbed,  with  varying  loss  of  muscular  power.  Pain 
may  be  present,  referred  to  the  spine,  or  along  the  distribution  of  the  sensory 
nerves,  with  or  without  loss  of  sensation. 

One  or  more  of  the  nerves,  sensory  or  motor,  may  be  affected  by  pressure  from 
gummata,  or  connective-tissue  changes  in  the  neurilemma,  or  the  presence  of 
exostoses  or  other  neoplasms. 

Bones. — Periostitis  and  ostitis  is  observed  more  frequently  in  the  bones  of  the 
skull,  along  the  spine  of  the  tibia,  and  in  the  clavicle,  than  in  other  parts  of  the 
osseous  system.  The  enlargements  are  in  some  instances  extensive,  and  pain  on 
palpation  may  be  elicited. 

Gummata  are  developed  upon  or  beneath  the  periosteum,  forming  soft,  semi- 
fluctuating  swellings,  elliptical  or  circular  in  shape,  and  from  half  an  inch  to  an 
inch  or  more  in  diameter.  These  nodules,  while  not  painful  under  ordinary  pres- 
sure, are  the  seat  of  exacerbations  of  pain  which  are  usually  experienced  at  night. 
They  frequently  break  down  in  ulceration  which  involves  necrosis  of  the  under- 
lying bone. 

When  the  inflammatory  process  is  violent,  extensive  destruction  may  occur.  A 
peculiar  type  of  bone  disease  is  known  as  osteitis  rarefaciens,  in  which  there  is 
no  suppuration  or  exfoliation,  a  portion  of  the  bone  substance  undergoing  absorp- 
tion, giving  to  the  part  involved  a  porous  or  worm-eaten  appearance. 

In  certain  cases  of  syphilitic  hypertrophy  of  the  bones  the  entire  cancellous 
portion  may  be  replaced  by  a  dense  eburnated  structure. 

Joints. — Synovitis,  with  thickening  of  the  membrane  and  ligaments,  may 
occur   with   impairment   of   motion   and   pain   of   a   dull    character.      In   severer 

cases    the    cartilages    and    bones 

^,-j,-^^^  may  become  involved,  leading  to 

-— ^^T--^  -  — =-^.  osteo-arthritis  and  destruction  of 

the  joint. 


Fig.  803. — Syphilitic  arteritis.  Section  of  basilar;  E, 
lumen  of  vessel  about  two  thirds  filled  with  new 
formation  at  A  B;  C,  media;  D,  muscular  layer  and 
adventitia.  From  a  patient  dead  from  syphilis. 
(Specimen  of  the  author's,  drawn  by  Dr.  Wardwell. 
Magnified  about  40  diameters.) 


Fig.  804. — Syphilitic  arteritis.  Section  of 
small  artery  of  cerebellum,  magnified  30 
diameters,  a,  lumen  of  vessel ;  c,  thick- 
ened inner  coat;  d,  muscular  coat;  e^ 
outer  coat.     (After  Greenfield.) 


Heart  and  Vessels. — Fatty  degeneration  of  the  heart  muscle  following  syphi- 
litic myocarditis  and  the  formation  of  gummata  upon  the  jDericardium  or  within 
the  muscular  walls,  are  the  chief  lesions  of  this  organ  in  the  tertiary  period.  The 
pericardium  may  also  be  affected,  and  in  like  manner  the  endocardium,  which  may 
undergo  atheromatous  degeneration  or  give  rise  to  vegetations.  The  capillaries, 
always  affected  in  the  first  and  second  stages,  are,  as  a  rule,  not  so  seriously  involved 
in  the  later  stages  as  the  arteries.     The  veins  are  rarely' affected.     Arteritis,  espe- 


THE   VENEREAL   DISEASES  767 

cially  of  the  variety  known  as  endarteritis  obliterans,  is  one  of  the  most  common 
and  grave  lesions  of  chronic  syi^hilis  (Figs.  803,  80-1).  While  the  larger  trunks 
are  involved,  the  more  characteristic  changes  occur  in  the  terminal  arteries  and 
arterioles.     The  cerebral  vessels  are  especially  susceptible. 

Lymphatics. — Gummatous  deposits  occasionally  take  place  in  the  lymphatic 
glands  in  the  tertiary  period.  The  superficial  set  may  break  down  and  discharge 
their  contents.  The  deep  glands  undergo  granular  degeneration  with  absorption 
or  the  gummatous  material  undergoes  caseous  or  calcareous  degeneration. 

Respiratory  System:  Nose. — The  mucous  membrane  may  be  thickened,  or  may 
be  more  or  less  destroyed  by  ulceration.  The  cartilage  and  bony  framework  are 
not  infrequently  destroyed,  and  in  neglected  cases-  lead  to  marked  sinking  in  of 
this  organ  with  great  cleformity. 

Larynx. — The  mucous  membrane  of  the  larynx  may  be  thickened  or  the  seat 
of  ulcers  or  vegetations.  Chondritis  and  perichondritis  are  not  infrequent,  and 
stricture,  more  or  less  complete,  may  occur  from  cicatricial  contraction.  The  larynx 
is  occasionally  the  seat  of  gummata,  while  the  trachea  and  bronchi  are  subject  to 
similar  lesions  inducing  stricture. 

In  the  lungs  the  principal  lesions  are  chronic  interstitial  or  fibrous  pneumonia, 
and  more  or  less  widely  disseminated  gummatous  deposits,  usually  in  the  lower 
portions  of  these  organs. 

Digestive  System:  Mouth. — Superficial  ulcers  of  the  walls  of  the  buccal  cavity 
are  frequent.  Deep,  destructive  ulcers  are  rare.  In  the  palate,  as  result  of  gum- 
matous deposits  or  general  infiltration,  at  times  rapid  and  irreparable  destruction 
of  tissue  may  occur.  The  curtain  of  the  soft  palate  may  be  destroj'ed,  the  bony 
septum  between  the  mouth  and  nose  perforated,  while  in  extreme  cases  the  pillars 
of  the  fauces  and  the  pharynx  may  be  involved. 

Tongue. — Gummatous  deposits  may  occur  in  any  portion  of  this  organ,  where 
they  tend  to  break  down,  giving  rise  to  ulcers  varying  in  size  and  depth. 

The  other  principal  lesion  of  the  tongue  in  the  tertiary  period  is  more  or  less 
widely  difEused  connective-tissue  hyperplasia,  giving  rise  to  a  varying  degree  of 
enlargement.  As  the  new-formed  tissue  contracts  it  gives  to  the  organ  a  lobulated 
appearance,  the  boundaries  of  the  lobules  being  well-marked  fissures  in  the  line 
of  the  contracting  bands. 

Oesophagus. — Stricture  of  the  oesophagus  may  occur  from  connective-tissue 
hyperplasia,  or  cicatricial  contraction  following  ulcer;  from  mechanical  obstruc- 
tion caused  by  gummatous  deposits ;  by  pressure  from  exostoses,  aneurisms,  enlarged 
glands,  etc.  Syphilitic  rdcers  of  the  stomach  and  bowels  have  been  observed, 
though  rarely.  Gummata  form  here,  however,  with  a  certain  degree  of  frequency, 
and  stricture  of  the  pylorus  and  alimentary  canal  near  the  rectum  is  known  to 
occur  in  a  fair  proportion  of  cases.  The  rectum  is  especially  liable  to  become 
seriously  involved  in  the  late  manifestation  of  syphilis.  Of  the  solid  viscera,  the 
liver  is  most  seriously  affected.  The  pathological  changes  are :  connective-tissue 
hyperplasia,  or  chronic  interstitial  hepatitis,  or  syphilitic  cirrhosis,  which  may  be 
general  or  local;  gummata  in  any  portion  of  the  organ;  and  waxy  degeneration 
from  long-continued  general  sepsis. 

The  spleen  may  undergo  similar  changes  while  the  pancreas  is  rarely  afEected. 

Genito-urinary  System. — Amyloid  degeneration  of  the  kidneys  occurs  as  a  result 
of  the  long-continued  sepsis  of  syphilis.  The  fibrous  stroma  of  this  organ  becomes 
thickened,  with  consequent  atrophy  of  the  excretory  or  glandular  elements  (chronic 
interstitial  nephritis). 

Gummata  of  the  kidney  is  not  as  common  as  in  other  viscera. 

Orchitis,  rarely  met  with  in  the  secondary  stage,  is  essentially  a  late  manifesta- 
tion of  this  disease.  Syphilitic  orchitis  should  be  suspected  in  all  cases  of  tumor 
of  this  organ  in  which  there  is  a  history  of  specific  infection.  It  is  apt  to  occur 
in  both  organs  about  the  same  time.  The  enlargement  is  smooth  and  spherical, 
'and  when  lifted  conveys  the  sense  of  unusual  weight.  It  is  not  painful  beyond 
the  sense  of  dragging.  Slight  hydrocele  not  infrequently  accompanies  this  form 
of  orchitis. 

The  testicles  are  not  exempted  from  gummatous  deposits.     In  rare  instances 


768 


THE   VENEREAL   DISEASES 


these   break   down,   causing   more   or   less   destruction   of  the   substance  of   these 
organs. 

The  Eye. — Syphilitic  iritis  occurring  in  the  second  stage  may  also  occur  as  a 
later  manifestation.  Inflammation  of  the  sclera,  choroid  and  ciliary  bodies,  lens 
and  capsule,  retina,  and,  though  rarely,  of  the  optic  nerve,  are  of  varying  fre- 
quency in  the  tertiary  period. 

Lesions  of  the  muscles  may  be  due  to  connective-tissue  new  formations  between 
the  fasciculi,  resulting  in  granular  degeneration  of  the  muscle  substance  and  con- 
traction of  the  new  tissue.  It  may  occur  in  the  second  as  well  as  in  the  third 
stage  of  this  disease.  Gummata  are  rarely  met  with.  Inflammation  in  the  ten- 
dons and  their  sheaths  may  also  occur. 

The  fingers  and  toes,  during  the  tertiary  period,  in  a  certain  proportion  of  cases 
become  the  seat  of  gummatous  deposits ;  the  skin  and  subcutaneous  tissues  may 
be  infiltrated,  or  the  bones  and  cartilages  may  be  involved.  When  confined  to  the 
soft  parts,  the  entire  organ  will  appear  swollen,  and  purple  or  reddish  in  color. 
When  the  bone  is  the  seat  of  the  deposit,  it  may  be  limited  to  a  single  phalanx  or 
invade  all  the  bones  of  the  finger  (Fig.  805).  The  process  terminates  in  ulcer, 
necrosis,  or  granular  degeneration  of 
the  cells  of  the  new  tissue,  and  absorp- 
tion. 

Pathology  of  Syphilis.— The  chief  g^Sfif®  "'#"!!'©  I^^ 

feature  in  the  pathology  of  sj-philis  in  "■     -   - 


.^6 


^^~ 


^^&->r- 


-Syphilitic  dactylitis, 
and  Bxunstead.) 


(After   Bergh 


Fig.  S06. — Section  through  a  hard  chancre:  a, 
round-celled  infiltration ;  h,  large  mononuclear 
cells :  and  c,  polynuciear  giant  cells.  HEema- 
toxylin  staining.       X  300. 


all  of  its  stages  is  the  proliferation  of 
an  embryonic  tissue,  usually  of  a  type 
so  low  that  it  is  not  capable  of  organization  into  a  definite  tissue.  From  the  initial 
lesion  and  the  primary  lymphangitis  and  adenitis  to  the  final  involvement  of  the 
viscera,  this  cell  proliferation  continues.  The  accumulation  of  these  so-called 
lymphoid  cells  in  and  around  the  capillary  loops  of  the  cutaneous  papillse,  which 
produce  a  macular  or  papular  syphilide  in  one  individual  whose  tissues  are  resist- 
ant, will  produce  a  squamous  or  vesicular  eruption  in  another,  or  a  pustular  S5'ph- 
ilide  in  a  weal^ier  subject  who  has  the  unfortunate  inheritance  of  a  gouty,  scrofu- 
lous, or  tubercular  dyscrasia.  Or  a  papular  lesion  of  the  first  stage  in  a  patient 
in  good  nutrition  may  be  suj^erseded  by  a  rupia  in  the  tertiary  j)eriod  when  assim- 
ilation is  impaired. 

If  the  initial  lesion  of  syphilis  is  excised  and  examined  with  the  microscope, 
the  following  conditions  will  be  observed :  The  epidermis  in  the  immediate  vicinity 
of  the  ulcer  is  more  or  less  completely  destroyed.  The  membrane  which  covers 
the  floor  of  the  ulcer  is  composed  of  pus  cells,  fragments  of  epidermal  cells,  cells 
of  the  Malpighian  layer,  and  fragments  of  connective  tissue  and  other  detritus. 
These  elements  vary  in  proportion  as  the  process  of  necrobiosis  is  limited  or  ex- 
tensive. In  the  deeper  portions  of  the  Malpighian  layer,  and  in  and  around  the 
papillse  where  these  layers  are  not  wholly  destroyed,  and  in  the  connective-tissue 
layer  of  the  skin,  there  is  a  general  infiltration  with  the  embryonic  cells  of  the 
syiDhilitic  process. 

The  arterioles,  veins,  and  capillaries  are  more  or  less  completely  occluded.  The 
cell  proliferation  is  especially  marked  in  the  arterioles,  the  adventitia  and  intima 
are  thickened,  the  thickening  being  more  marked  in  the  latter,  while  the  lumen 


THE   VENEREAL   DISEASES  769 

of  the  vessel  is  more  or  less  encroached  upon  by  the  new-formed  tissue.  The 
venules  undergo  analogous  changes.  The  walls  of  the  lymph  channels  are  thick- 
ened, and  many  of  these  vessels  are  crowded  with  cells.  The  infiltration  is,  how- 
ever, limited  to  the  immediate  borders  of  the  ulcer,  and  the  line  between  this  and 
the  uninvaded  tissue  is  sharply  defined.  As  the  mass  of  cells  gradually  obstruct 
the  vessels,  the  nutrition  of  the  new  tissue  is  interfered  with,  and  it  either  undergoes 
granular  metamorphosis  or  breaks  down  more  rapidly  as  a  slough.  The  absence  of 
pain  in  the  chancre  is  also  explained  by  the  gradual  pressure  upon  the  terminal 
nerves  and  the  comparative  dryness  of  the  typical  sore  by  the  arterial  occlusion. 

The  lymphatics  immediately  around  the  ulcer,  and  those  leading  from  it  to  the 
nearest  glands,  are  more  or  less  filled  with  the  new  cells,  and  their  walls  appear 
thicker  than  normal. 

The  changes  which  occur  in  the  glands  in  the  earlier  stages  of  syphilis  consist 
in  a  h3'perplasia  of  tlie  connective-tissue  cells  of  the  stroma  and  thickening  of  the 
fibrous  fraraework,  together  witli  an  increase  in  the  cell  elements  of  the  gland  sub- 
stance proper. 

The  cutaneous  lesions  of  secondary  syphilis  result  from  the  more  or  less  com- 
plete obstruction  of  the  capillary  loops  of  the  papilla  by  the  cells  of  this  indifferent 
tissue.  The  walls  of  the  capillaries  imdergo  degeneration;'  the  coloring  matter  of 
the  blood  escapes,  causing  the  peculiar  staining  of  the  syphilides.  In  the  macular 
syphilide  the  abnormal  cell  accumulation  is  less  than  in  tlie  papular  eruption.  The 
changes  which  occur  in  mucous  patches  differ  very  slightly  from  those  described 
in  the  cutaneous  lesions.  The  epidermis  soon  breaks  down;  the  Malpighian  layer 
and  papillffi  are  infiltrated  with  the  cell  elements;  while  the  cajjillaries,  arterioles, 
and  lymphatic  vessels  undergo  changes  almost  identical  with  those  described  in  the 
initial  lesion. 

In  the  later  or  tertiary  lesions  of  the  skin  in  S3'philis  the  infiltration  is  deeper. 
Cutaneous  gummata  consist  of  aggregations  of  the  cell  elements  heretofore  de- 
scribed, which  are  crowded  into  the  subcutaneous  areolar  tissue,  into  the  connective 
tissue  of  the  true  skin,  in  the  walls  of  and  just  outside  the  vessels,  while  the  endo- 
tlielia  of  these  vessels  undergo  proliferation  and  aid  in  their  occlusion.  Ulceration 
ensues  from  the  rapid  arrest  of  nutrition,  and  the  process  of  necrobiosis  is  aided 
by  the  depressed  condition  of  the  tissues  which  usually  exists  in  the  tertiary  stage 
of  sypliilis.  The  tertiary  lesions  of  tlie  mucous  surfaces  are  analogous  to  those  of 
the  integument. 

The  pathology  of  visceral  syphilis  presents  two  distinct  morbid  processes:  (1) 
the  hyperplasia  of  the  connective-tissue  stroma  of  the  organs  (cirrhosis)  ;  and 
(2)  the  aggregation  of  the  syphilitic  embryonic  cells  (gumma).  The  character 
of  these  changes  iu  the  dift'erent  organs  has  been  given. 

Diagnosis. — In  a  typical  case  of  acquired  syphilis  a  diagnosis  may  be  made 
upon  the  following  symptoms:  1,  an  ulcer  in  appearance  and  behavior  like  that 
described  as  belonging  to  the  initial  lesion  of  this  disease,  the  sore  occurring  not 
less  than  ten  days,  and  usually  about  the  twentieth  day,  after  an  exposure;  8,  in- 
duration and  enlargement  of  the  nearest  h'mphatic  glands  occurring  in  from  eight 
to  fourteen  days  after  the  appearance  of  the  ulcer ;  3,  after  from  two  to  four  weeks 
of  seeming  arrest  of  the  infection,  the  development  of  headache,  pain  in  the  bade, 
slight  febrile  movement,  with  an  eruption  (sixth  to  seventh  week  after  the  appear- 
ance of  the  sore)  over  all  or  a  portion  of  the  body,  accompanied  with  an  unusual 
sense  of  dryness  or  soreness  of  the  mouth,  pharynx,  or  fauces;  4,  following  or 
occurring  with  these  symptoms,  general  adenitis. 

In  the  majority  of  cases,  excluding  even  those  in  which  the  sore  is  concealed, 
as  in  the  urethra,  etc.,  on  account  of  mixed  infection  little  value  can  be  placed 
upon  the  appearance  of  the  ulcer  at  the  point  of  inoculation.  The  classical  "  initial 
lesion  "  of  syphilis,  with  its  well-defined  margin  of  induration,  feeling  like  a  "  split 
pea  "  or  piece  of  cartilage  when  grasped  between  the  thumb  and  finger ;  the  ab- 
sence of  pain  and  peripheral  inflammation ;  the  peculiar  "  scooped-out "  concavity 
of  tlie  sore,  the  surface  of  which  is  covered  with  a  scanty,  serous  transudation,  is 
so  frequently  absent  in  cases  in  which  the  later  and  unmistakable  signs  of  this 
disease  are  developed,  that  it  alone  can  scarcely  be  relied  upon  in  arriving  at  a 


770  THE   VENEREAL   DISEASES 

diagnosis.  As  stated  heretofore,  the  syphilitic  virus  may  be  lodged  in  and  ab- 
sorbed from  a  phagedenic  ulcer  in  which  not  a  single  feature  of  the  speciiic  sore 
is  present.  The  same  is  true  of  the  herpetic  ulcer,  or  that  resulting  from  trau- 
matism or  the  inoeurlation  of  any  form  of  virus.  All  of  these  ulcers  are  grouped 
under  the  heading  of  "  mixed  sores  "  or  mixed  infection. 

Induration  of  the  glands  is  more  reliable  in  a  diagnostic  sense.  When  the 
typical  initial  lesion  is  present,  the  ensuing  adenitis  is  also  typical.  In  the  inguinal 
region  one  gland  of  the  group  after  another  is  enlarged  and  becomes  indurated. 
The  process  is  slow  and  deliberate.  There  is  no  periadenitis,  the  glands  do  not 
adhere  to  each  other  and  the  intervening  tissues,  nor  to  the  integument.  Each 
body  may  be  distinctly  made  out  by  palpation  and  moved  beneath  the  skin  inde- 
pendently. There  is  no  tenderness,  and  the  gland  is  leathery  to  the  touch.  Even 
when  the  sore  is  mixed,  if  the  phagedenic  or  inflammatory  process  is  not  severe, 
the  adenitis  is  more  apt  to  be  specific  than  inflammatory,  and  will  possess  the 
features  of  syphilitic  bubo  in  a  suflicient  degree  to  admit  of  recognition.  When 
the  specific  infection  is  complicated  with  a  typical  phagedenic  ulcer  or  gonorrhoea,, 
the  resulting  bubo  does  not  possess  a  single  appreciable  feature  of  syphilitic  adenitis. 

The  eruption  of  syphilis  is,  of  all  the  s3'mptoms  of  this  disease,  the  most  reli- 
able. When  the  sore  is  mixed,  and  the  character  of  the  adenitis  doubtful,  the 
early  cutaneous  and  mucous  lesions  are,  in  the  vast  majority  of  cases,  appreciable' 
and  unmistakable.  Headache,  rise  in  temperature,  pains  in  the  back,  etc.,  are 
confirmatory  sjinptoms,  but  independently  of  no  value.  The  same  may  be  said  of 
dryness  or  soreness  of  the  mouth,  pharynx,  and  fauces.  Lastly,  general  adenitis, 
which  occurs  in  a  varying  degree  in  all  cases  of  syphilis  in  which  mercurialization 
has  not  been  affected  at  a  very  early  date,  is  a  strong  confirmatory  sjTuptom, 
and  of  great  value  in  diagnosis  if  all  the  other  lesions  have  escaped  observation. 
The  greatest  importance  is  attached  to  induration  of  the  epitrochlear,  and  to 
the  occipital  and  post-niastoid  glands.  The  former  can  scarcely  be  recognized  in 
their  normal  state.  In  general  adenitis  a  single  body,  feeling  like  a  small  bean 
in  shape,  may  be  recognized  at  the  inner  aspect  of  the  arm  just  above  the  elbow,, 
where  it  lies  superficial,  and  internal  to  the  basilic  vein.  When  any  inflammatory- 
process  exists  in  the  member  beyond  the  elbow,  the  enlarged  gland  possesses  no 
specific  diagnostic  value.  In  like  manner  lesions  of  the  scalp,  face,  or  mouth  may 
cause  enlargement  of  the  occipital  or  mastoid  lymphatic  glands. 

A  diagnosis  of  syphilis  in  the  tertiary  period  must  depend  upon  a  careful  study 
of  the  history  of  the  case  and  the  presence  of  one  or  more  of  the  lesions  which, 
belong  to  this  stage,  and  which  have  been  fully  described. 

The  importance  of  commencing  treatment  at  the  earliest  possible  moment  can- 
not be  overestimated.  With  a  characteristic  chancre  present,  the  surgeon  should 
administer  mercury  without  waiting  for  adenitis  or  the  cutaneous  lesions.  If  the- 
initial  lesion  shows  a  mixed  infection,  the  most  careful  scrutiny  should  be  made,, 
if  possible,  into  the  source  of  the  inoculation  in  order  to  determine  the  diagnosis 
at  once  and  justify  vigorous  measures.  Even  in  cases  of  doubt,  it  would  be  a  wise 
precaution  to  lean  to  the  side  of  treatment,  since  this  insures  safety  and  can  do- 
no  harm  if  properly  managed.  If  delayed  until  the  characteristic  cutaneous  lesions, 
are  present,  the  process  of  infection  is  so  far  advanced  that  it  cannot  be  so  readily 
checked,  nor  the  poison  so  easily  neutralized  and  eliminated  as  when  the  treatment 
is  instituted  at  an  earlier  date. 

Prognosis. — A  favorable  prognosis  in  syphilis  will  depend  upon  (1)  the  phys- 
ical condition  of  the  individual  affected  at  the  time  of  inoculation;  (2)  the  early 
recognition  of  the  disease  and  the  prompt  institution  of  treatment;  (3)  the  faith- 
ful and  energetic  cooperation  of  the  physician  and  patient  in  carrying  out  the 
measures  indicated. 

That  syphilis  is  a  curable  disease  there  can  be  no  doubt.  Under  favorable  con- 
ditions the  symptoms  disappear,  leaving  little  or  no  trace  of  the  infection.  Its 
severe  results  are  seen  in  individuals  with  an  inherited  or  acquired  dyscrasia,  with 
impaired  nutrition,  and  in  neglected  cases. 

Even  in  the  worst  class  of  cases,  the  prognosis  is  not  wholly  unfavorable  if 
proper  treatment  is  instituted  and  maintained. 


THE   VENEREAL   DISEASES  771 

When  the  initial  lesion  is  early  seen  and  recognized  and  treatment  at  once 
instituted,  late  secondary  and  tertiary  manifestations  need  not  appear.  Even  when, 
by  reason  of  the  uncertain  character  of  the  early  lesion,  a  positive  diagnosis  cannot 
be  made  until  the  eruption  is  seen,  a  favorable  prognosis  may  be  given. 

Treatment. — The  treatment  of  syphilis  may  be  divided  into  (1)  measures  which 
tend  to  destroy  the  potency  of  the  virus  and  aid  in  the  absorption  of  the  inflamma- 
tory products  of  this  disease,  and  (2)  those  which  tend  to  improve  the  nutrition 
of  the  tissues.  Both  are  essential  to  the  successful  management  of  this  formidable 
disease. 

Nothing  is  more  satisfactorily  demonstrated  than  the  power  of  mercury  to 
neutralize  and  destroy  the  virus  of  syphilis. 

The  management  of  a  ease  of  sypliilis  sliould  be  carried  on  for  a  period  of  at 
least  two  years.  The  person  affected  sho^ild  be  impressed  with  the  gravity  of  the 
situation,  and  the  certainty  of  disaster  if  the  rules  laid  down  are  not  strictly 
obeyed.  All  excesses  should  be  prohibited.  In  certain  cases,  where  digestion  and 
assimilation  are  impaired,  a  small  quantity  of  whisky,  claret,  or  sherry  may  be 
taken  with  the  meals.  Sexual  indulgence,  if  from  no  other  than  humanitarian 
motives,  should  cease  for  at  least  a  year  from  the  appearance  of  the  initial  lesion. 
The  child  of  parents,  either  of  whom  is  within  the  first  year  of  syphilitic  inocula- 
tion, becomes  the  victim  of  a  dyscrasia  which,  if  not  fatal  to  life,  is  fatal  to  the 
perfect  usefulness  of  its  possessor. 

In  addition  to  the  danger  of  direct  inoculation  during  the  prevalence  of  the 
chancre,  is  that  of  infection  to  the  mother  from  the  foetus  in  utero  or  the  child 
in  the  act  of  parturition.  A  patient  under  treatment  for  syphilis  should  retire 
early,  avoid  excessive  use  of  the  eyes,  especially  at  night,  sudden  changes  in  tem- 
perature, and  all  articles  of  diet  which  are  not  readily  digestible. 

Of  the  preparations  of  mercury,  preference  should  be  given  to  the  protoiodide. 
It  is  convenient  to  administer  this  in  pills  of  one  quarter  grain  each.  One  of  these 
pills  should  be  given  three  times  a  day,  an  hour  after  eating. 

The  indications  for  a  diminution  of  the  quantity  are  pain  of  a  cramplike 
nature  in  the  stomach  or  bowels,  with  or  without  diarrhcea,  and  any  symptom  of 
salivation.  Clinical  experience  teaches  that  salivation  does  not  occur  with  the 
protoiodide  until  after  a  colicky  diarrhoea,  which  should  be  a  timely  warning  for 
diminishing  the  dose.  If  diarrhoea  results,  it  is  advisable  to  administer  about 
one  quarter  of  a  grain  of  opium,  or  to  reduce  the  number  of  pills.  In  -certain 
conditions  inunctions  with  mercuric  ointment  are  of  great  value. 

Salivation  may  be  guarded  against  by  careful  observation  of  the  gums.  At 
the  earliest  indications  of  tenderness  felt  when  the  teeth  are  firmly  pressed  to- 
gether, or  when  direct  pressure  is  made  upon  the  alveolus,  the  dose  should  be 
diminished,  or,  if  necessary,  discontinued  for  a  few  days. 

It  will  usually  suffice  to  administer  one  quarter  grain  of  protoiodide  three  times 
a  day  for  the  first  month,  and  at  the  expiration  of  this  time  to  increase  to  one 
grain.  It  will  rarely  be  necessary  to  give  more  than  this  quantity,  although  in 
some  cases  the  full  beneficial  efl^ects  of  the  remedy  may  not  be  realized  until  a 
larger  dose  is  given.  The  mercury  should  be  continued  without  interruption — 
excepting  for  the  reasons  just  given — for  the  first  six  months.  At  the  expiration 
of  this  period  it  is  a  good  plan  to  discontinue  the  protoiodide  for  two  weeks,  and 
then  administer  the  iodide  of  potassium  three  times  a  day  for  one  month.  This 
should  then  be  stopped  and  the  pills  resumed  for  a  period  of  two  months,  and  so 
on,  alternating  these  two  remedies  to  the  end  of  the  first  year.  For  the  first  six 
months  of  the  second  year  the  alternations  should  be  equal — i.  e.,  one  month  of 
the  potassium  salt  and  the  next  of  the  protoiodide.  For  the  last  six  months  of 
treatment  the  iodide  of  potassium  should  alone  be  given. 

In  addition  to  the  foregoing  it  is  of  great  importance  that  tonics  should  be 
administered  from  the  commencement  of  treatment,  and  especially  in  delicate  pa- 
tients. When  protoiodide  of  mercury  cannot  be  obtained,  the  biniodide  in  ^  to 
yV  gr.  may  be  substituted. 

When  mercuric  inunctions  are  indicated,  proceed  as  follows:  Take  about  a  tea- 
spoonful  of  mercuric  ointment  and  rub  it  well  into  the  skin  of  the  groin  and  under 


772  THE   VENEREAL   DISEASES 

the  arms.  Or  spread  the  ointment  on  lint  and  apply  it  to  these  parts,  holding 
it  in  place  by  lightly  fitting  clothes  or  bandages.  It  should  be  used  only  at  night, 
and  removed  upon  rising  by  washing  with  warm  water  and  soap. 

The  hypodermic  injection  of  corrosive  sublimate  in  the  treatment  of  syphilis, 
while  objectionable  on  account  of  the  annoyance  produced  by  the  insertion  of  the 
solution  beneath  the  skin,  may  become  necessary  in  certain  patients  who  cannot  be 
brought  under  its  influence  in  any  other  manner. 

The  injections  should  be  made  imder  the  skin  of  the  back,  and  with  most 
careful  asepsis.  From  ^^  to  -J-  gr.  of  corrosive  sublimate  may  be  used  once  or 
twice  a  day,  watching  the  effect  closely.  A  few  minims  of  two-per-cent  cocaine 
preceding  the  mercury  will  lessen  the  pain. 

Within  recent  years  very  remarkable  success  in  the  treatment  of  syphilis  has 
been  claimed  by  well-known  specialists  from  the  intramuscular  injection  of  a  ten- 
per-eent  suspension  of  the  salicylate  of  mercury  in  liquid  petroleum.  According 
to  Gottheil,  who  recommends  the  following  formula,  it  never  produces  abscess  ^ : 

J^  Hydrargyri  salicylatis 5  gm.  or  c.c. 

Petrolati  liquid!    50  gm.  or  c.c. 

M.  Sig. :     For  hypodermic  injection. 
■^  c.c.  =  .05  gm.  of  the  mercury. 
10  nx    ^  1  grain  of  the  mercury. 
5  TTl,    ^  -J  grain  of  the  mercury. 

This  must  be  thoroughly  shaken  before  using.  Of  the  above  mixture,  10  minims 
are  equal  to  one  grain  of  the  salicylate,  containing  -^^%  grain  of  metallic  mercury. 

These  injections  are  given  at  intervals  of  four  clays  or  more  and  the  greatest 
aseptic  care  should  be  taken.  The  solution  is  rapidly  absorbed.  Gottheil  holds 
that  it  is  not  necessary. to  sterilize  the  injection  fluid,  jjrovided  ordinary  care  is 
taken  to  prevent  it  from  contamination.  The  needles  should  be  about  21  gauge. 
The  site  of  injection  should  be  about  half-way  between  the  intergluteal  fold  and 
a  line  running  parallel  to  it  and  dividing  the  buttocks  into  halves.  It  should  be 
made  on  alternate  sides,  dividing  each  half  of  the  area  into  three  injection  sites, 
so  that  the  unindurated  tissue  may  be  used  for  each  separate  injection. 

The  first  injection  should  be  5  minims  (^  grain,  .03  gm.).  Two  days  later  this 
should  be  increased  to  7  minims;  four  days  later,  10  minims;  and  from  this  time 
on  the  average  case  requires  about  1  grain  every  seven  days.  Some  require  more 
than  others,  but  the  dosage  must  be  determined  by  a  careful  study  of  the  effect. 

In  view  of  Dr.  Gottheil's  large  experience  and  the  results  reported  by  him,  this 
method  of  treatment  strongly  commends  itself. 

In  the  treatment  of  the  tertiary  lesions  of  syphilis  practically  the  same  rule  of 
practice  should  be  adopted  as  just  given  for  the  second  year  following  the  appear- 
ance of  the  initial  lesion.  The  employment  of  iodide  of  potassiiim  in  full  doses 
hastens  the  absorption  of  the  inflammatory  products  of  this  stage,  while  the  pro- 
toiodide  destroys  the  potency  of  the  virus.  Both  remedies  should  be  administered 
in  doses  as  large  as  can  be  borne  without  interfering  with  the  functions  of  the 
digestive  organs  or  producing  any  serious  constitutional  disturbances. 

In  the  treatment  of  gumma  and  the  destructive  cutaneous  tertiary  lesions  met 
with  in  neglected  cases  large  doses  of  iodide  of  potassium  are  imperative.  The 
dose  should  be  gradually  increased  until  either  the  symptoms  of  iodism  are  present 
or  the  lesions  disappear.  As  much  as  960  grains  a  day  have  been  employed  with 
curative  efl^ect. 

Inherited  Sypli.ilis. — The  foetus  may  become  syphilitic -from  a  syphilitic  father 
or  mother.  If  pregnancy  occurs  within  the  first  year,  and  especially  in  the  first 
six  months  of  the  disease  in  the  mother,  the  child  becomes  inoculated,  either  dying 
in  utero,  or,  if  carried  to  term,  usually  perishes  within  a  few  weeks  after  its  birth. 
If,  however,  the  disease  is  recognized  and  proper  treatment  instituted,  a  more 
favorable  prognosis  may  be  made. 

1  "  International  Clinics,"  Vol.  Ill,  Fourteenth  Series.  "  New  York  Medical  Journal,"  June 
30,  1906.     "  Journal  of  the  American  Medical  Association,"  August  3,  1907. 


THE   VENEREAL   DISEASES  773 

In  the  second  year  after  infection,  if  properly  treated,  a  mother  may  bear  a 
non-syphilitic  child,  although  the  chances  are  against  complete  immunity.  During 
the  third  and  each  succeeding  year,  under  judicious  management,  the  prog-nosis 
is  still  more  favorable. 

A  female  patient  shoidd  be  advised  of  the  great  danger  of  pregnancy  within 
the  two  years  immediately  following  inoculation.  When  she  has  been  under  con- 
stant and  proper  treatment  for  this  length  of  time,  and  has  been  perfectly  free 
from  symptoms  for  one  year,  the  gravity  of  the  danger  is  diminished.  If  she  has 
not  been  treated,  she  should  under  no  circumstances  be  made  liable  to  pregnancy. 
In  case  such  a  woman  becomes  pregnant,  she  should  be  treated  carefully  for  syph- 
ilis, and  in  this  way  the  infection  of  the  child  may  be  modified,  if  not  prevented. 

It  is  stated  that  the  virus  of  syphilis  may  be  conveyed  by  the  spermatic  elements, 
and  the  embryo  thus  become  inoculated.^  The  prognosis  is  more  favorable  in  pro- 
portion to  the  length  of  time  which  has  elapsed  after  the  initial  lesion,  and  to  the 
thoroughness  of  tlie  treatment  instituted.  A  syphilitic  man  should  not  beget  a 
child  within  two  years  after  the  initial  sore,  nor  at  any  later  period  unless  thor- 
ough treatment  has  been  instituted  and  one  year  has  elapsed  since  the  disappear- 
ance of  all  s3'mptoms  of  the  disease. 

Symptoms. — The  symptoms  of  specific  infection  in  the  child  manifest  them- 
selves usually  within  the  first  eight  or  twelve  weeks  after  birth.  Occasionally  the 
disease  is  latent,  and  the  symptoms  do  not  appear  until  a  variable  period  has 
elapsed.  Even  puberty  may  be  reached  before  it  is  evident.  Excepting  the  chan- 
cre, the  local  lymphangitis  and  adenitis,  the  evolution  of  the  symptoms  of  inher- 
ited syphilis  is  not  unlike  those  of  the  acquired  form.  The  lesions  are  cutaneous, 
mucous,  and  visceral. 

The  macular  or  papular  syphilide  occurs  in  most  cases,  and  may  be  distributed 
over  the  general  surface  or  confined  to  certain  limits.  It  is  usually  first  seen  upon 
the  abdomen,  and  from  this  starting  point  it  becomes  more  or  less  widely  distrib- 
uted. At  the  muco-cutaneous  margins,  and  in  the  folds  of  the  skin  where  irrita- 
tion is  greater  and  moisture  exists,  condylomata  are  not  infrequent,  and  are  often 
persistent.  Vascidar,  pustular,  and  tubercular  syphilides  occur  in  a  certain  pro- 
portion of  cases.  The  tubercular  form  is  rare.  The  pustular  form  (syphilitic 
pemphigus)  indicates  a  low  order  of  tissue  vitalitj',  and  justifies  an  unfavorable 
prognosis. 

Lesions  of  the  mucous  surfaces  occur  either  before  or  with  the  cutaneous  lesions. 
Papules  and  excoriations  (mucous  patches)  are  found  in  the  buccal  cavity,  on 
the  tongue,  fauces,  and  pharynx.  Fissures  of  the  lips  are  not  uncommon,  and 
especially  in  the  angles  of  the  mouth.  The  infection  of  the  mucous  membrane 
of  the  nose  and  air  passages  leads  to  the  distressing  coryza  and  cough  so  often  noticed 
in  syphilitic  infants.  Gummata  of  the  skin  and  of  all  organs  occur  in  the  same 
manner  and  with  the  same  pathological  significance  as  in  the  acquired  form. 

Treatment. — The  preparations  of  mercury  antagonize  the  virus  in  this  as  in 
the  acquired  form  of  syphilis.  The  careful  mercurialization  of  the  mother  during 
pregnancy  is  important  in  preventing  the  development  of  the  disease  in  its  severer 
forms,  inunction  with  the  ointment  of  mercury  shoidd  be  first  faithfully  tried 
in  the  treatment  of  syphilis  in  the  newly  born.  One  dram  of  mercury  to  one 
ounce  of  lard  is  the  proportion  recommended  by  Brodie.  This  is  spread  upon  a 
soft  flannel  belt  and  worn  continuously  around  the  patient's  waist.  The  ointment 
should  be  renewed  as  needed.  If  the  beneficial  effects  of  the  mercury  are  not 
secured  by  this  method,  the  internal  administration  or  the  intramuscular  injections 
may  be  tried. 

'  As  heretofore  stated,  a  non-syphilitic  mother  may  be  inoculated  from  a  syphilitic  child  in 
the  act  of  parturition.  That  the  mother  is  also  subjected  to  the  influence  of  this  virus  from  carry- 
ing the  offspring  of  a  syphilitic  father  is  proved  by  Colles'  law,  which  is,  that  a  previously  healthy 
mother  of  such  a  child  can  nurse  it  without  danger  of  chancre  of  the  nipple  and  syphilitic  infection, 
while  a  non-syphilitic  nurse  will  become  inoculated. 


CHAPTER    XXXVIII 

BURNS SCALDS SKIN-GRAFTING FROSTBITE FURUNCLE CARBUNCLE ULCERS 

GANGRENE 

Burns  and  scalds  are  classified  in  degrees  varying  from  tlie  mildest  form,  which 
produces  a  simple  inflammation  of  the  epidermis,  to  the  most  severe  form,  which 
destroys  all  the  tissues  or  organs  of  a  part.  The  gravity  of  the  prognosis  is  usu- 
ally in  proportion  to  the  extent  of  surface  of  the  integument  destroyed  rather 
than  to  the  depth  of  the  destructive  process.  Burns  of  the  head  and  face  are 
most  dangerous;  those  of  the  extremities  least  grave.  Eecovery  is  exceptional 
after  destruction  of  one  third  of  the  cutaneous  surface.  Death  may  result  from 
shock,  ulcer  of  the  duodenum,  or  exhaustion  from  prolonged  suppuration  and 
septic  absorption. 

The  history  of  a  slight  burn  or  scald  involving  only  a  limited  area  of  the 
integument,  and  not  extending  beyond  the  skin,  is  simply  one  of  local  disturbance. 
When,  however,  a  considerable  extent  of  tissue  is  involved,  symptoms  of  profound 
constitutional  disturbance  rapidly  supervene.  The  patient  is  seized  with  chills 
or  rigors,  suffers  excruciating  pain,  betrays  in  his  expression  the  extreme  anxiety 
felt  as  to  his  condition,  and  sinks  into  a  condition  of  collapse,  which  is  often  the 
prelude  to  a  fatal  issue.  When  not  rapidly  fatal,  the  duration  of  this  stage  is 
from  six  to  thirty-six  hours.  It  is  followed  by  the  stage  of  reaction  and  inflam- 
mation. The  character  of  the  febrile  movement  depends  upon  the  extent  of  the 
destruction  of  the  tissues,  and  upon  the  concurrence  of  certain  lesions  of  the  tho- 
racic and  abdominal  viscera.  Inflammation  of  the  duodenal  glands,  and  the 
formation  of  ulcer  with  perforation,  is  not  of  infrequent  occurrence  during  the 
second  week  after  the  accident.  Peritonitis,  pleuritis,  or  pneumonitis  may  add 
to  the  gravity  of  the  jjrognosis.  Laryngitis  and  bronchitis  are  apt  to  follow  the 
efforts  at  inspiration  in  the  presence  of  scalding  steam. 

Treatment. — The  immediate  indication  is  to  relieve  pain  by  the  administration 
of  morphia  hypodermically,  or  by  some  form  of  opium  by  the  rectum  or  stomach. 
Locally,  the  most  generally  convenient  remedy  is  a  saturated  solution  of  baking 
soda  in  water,  with  submersion  of  the  burned  surface,  if  possible,  or  a  mixture 
of  bicarbonate  of  soda  and  corn  starch,  each  one  teaspoonful  to  a  quart  of  water. 
This  should  be  applied  freely  to  the  burned  area  and  the  dressing  kept  wet  with 
the  solution.  This  should  be  followed,  after  five  or  six  hours,  by  applying  freely 
the  following  mixture: 

Ichthyol oSS- ; 

Cotton-seed    (or  olive)   oil O.ss. ; 

Limewater   O.ss. 

Mix  into  an  emulsion. 

This  should  be  continuously  applied  for  the  first  three  to  five  days  during  the 
stage  of  acute  inflammation.  In  order  to  bring  about  a  rapid  repair  of  the  skin, 
employ  the  following: 

Ichthyol    3j ; 

Diachylon  ointment,  )    --  c--. 

White  vaseline,       "     J  ^  ^' 

774 


BURXS,    SCALDS,    SKIX-GRAFTING,    FROSTBITE,    ETC.  775 

This  should  be  mixed  thoroughly.  If  these  remedies  are  not  convenient,  the 
following  may  be  substituted  with  equal  benefit : 

Lead  plaster,       ^ 

Liquid  albolene,  I    --  ^. 

Lanolin,  f  3J- 

Vaseline,  J 

Melt  together,  and,  when  cooling,  add  40  minims  of  iehthyol. 

Either  of  these  ointments  should  be  applied  thickly  on  the  soft  linty  side  of 
•canton  flannel,  surgeon's  lint,  or  on  several  layers  of  sterile  gauze.  The  appli- 
■cation  should  be  repeated  daily  at  first,  having  previously  opened  all  blebs  and 
being  careful  not  to  remove  the  epidermis  of  the  bleb,  as  this  may  be  revitalized 
and  greatly  accelerate  the  healing  process.  In  changing  the  dressing  it  is  very 
important  not  to  disturb  the  new-  granulations,  but  simply  to  wipe  around  the 
■edges  of  the  wound  for  cleansing  purposes,  and  not  wipe  over  the  granulations. 
Healing  is  seriously  delayed  by  mistaken  zeal  in  mopping  these  surfaces.  After 
Tiealing  is  welHunder  wav,  the  dressing  should  not  be  changed  oftener  than  every 
second  or  third  day. 

When  the  new  skin  becomes  white  and  spongy,  a  two-per-cent  ointment  of 
Tcsorcin  should  be  used.^ 

In  the  treatment  of  the  depression  or  shock  which  often  follows  severe  burns, 
stimulation  with  whiskv^  or  brandy,  by  enema  or  by  the  mouth,  is  indicated,  as 
"well  as  the  hypodermic  injection  of  morphia.  ISTormal  salt  solution  by  the  colon, 
•or  injected  into  the  areolar  tissue,  is  of  great  value  when  the  burn  is  extensive 
and  the  shock  profound.  The  use  of  opium  and  alcohol  should  he  made  with  a 
■certain  degree  of  caution  to  avoid  a  too  profound  narcosis  with  the  former,  while 
alcohol  in  excess  may  add  to  the  fever  of  reaction  which  follows  when  the  patient 
rallies  from  the  shock.  The  clothing  should  be  carefully  removed  and  the  burned 
surface  shielded  from  the  atmosphere  by  immersion,  when  possible,  in  a  strong 
solution  of  bicarbonate  of  soda. 

In  an  emergency,  when  the  foregoing  remedies  may  not  be  obtained,  a  coating 
■of  ordinary  white  lead,  as  mixed  for  use  in  painting  dwellings,  is  an  efficient 
protection  when  poured  over  the  burn.  Flour  sprinkled  over  until  all  the  excori- 
ated surface  is  well  hidden  is  a  method  of  treatment  applicable  in  almost  any 
■emergency.  Rubber-tissue  protective  or  oil  silk,  sterilized  and  laid  over  the  raw 
surface,  with  cotton  batting  applied  on  top  of  this  but  never  directly  upon  the 
burned  surface,  is  equally  efficient.  Lint,  or  a  soft  cloth  dipped  in  two-per-cent 
■carbolized  oil,  may  be  employed  directly  on  the  burn.  In  holding  these  various 
■dressings  in  place,  no  pressure  should  be  exercised.  In  the  not  infrequent  form 
-of  injury  in  which  the  back  and  posterior  aspects  of  the  extremities  are  chiefly 
involved,  the  prone  position  is  of  necessity  maintained. 

Skin-grafting. — ^AATien  the  destruction  of  integument  has  been  so  extensive  that 
in  the  process  of  cicatrization  the  granulating  surface  is  not  re-covered  by  skin, 
transplantation  must  of  necessitv'  be  practiced.  The  various  methods  are  by  slid- 
ing, grafting,  or  transplantation  en  masse.  In  all  the  operative  surgery  of  the 
skin,  no  method  gives  such  perfect  satisfaction  as  that  of  sliding,  in  which  a  flap 
■of  skin  is  dissected  up,  leaving  a  pedicle  sufl&ciently  broad  to  insure  its  blood 
supply.  The  loosened  skin  is  shifted  to  its  new  position  and  carefully  stitched  in 
place."  Wliile  the  loose  flap  may  be  quite  considerably  stretched  and  made  to  cover 
a  surface  larger  than  it  originally  occupied,  no  tension  whatever  should  he  made 
upon  the  pedicle.  In  severe  burns  of  the  face  it  is  often  possible  to  cover  in  very 
-extensive  defects  after  a  thorough  removal  of  all  cicatricial  tissue  by  sliding  a 
series  of  large  flaps  from  the  neck. 

Illmtrattve  Case. — As  the  result  of  a  Inirn  the  integument  upon  the  under  and 
anterior  surface  of  the  chin  had  been  destroyed  so  that  in  the  process  of  cica- 
trization the  corner  of  the  mouth  was  drawn  down  to  the  lower  border  of  the 

>  Prof.  Thurston  G.  Lusk. 


776  BURNS,   SCALDS,   SKIN-GRAFTING,   FROSTBITE,    ETC. 

inferior  maxilla,  exposing  the  teeth  and  gums,  and  permitting  a  continuous  leak- 
age of  saliva.  The  vermilion  border  of  the  lip  and  the  orbicularis  oris  muscle 
were  not  destroyed.  Thoroughly  removing  all  the  cicatricial  tissue,  the  orbicular 
muscle  and  the  lip  were  brought  back  to  their  normal  position,  leaving  an  exposed 
surface  from  the  middle  line  of  the  chin  and  lip  downward  two  and  a  half  inches 
wide,  extending  backward  to  near  the  angle  of  the  jaw.  The  area  exposed  by  this 
dissection  measured  two  and  a  half  by  four  inches.  By  making  careful  measure- 
ments and  cutting  a  piattern  of  sterile  sheet-rubber,  an  incision  parallel  with  the 
lower  margin  of  this  wound  and  three  inches  below  was  made  across  the  neck,  the 
flap  so  shaped  being  long  enough  when  dissected  loose,  and  all  the  subcutaneous 
fat  carefully  removed,  to  be  swung  upward  and  fill  in  the  most  distant  angle  of 
the  raw  surface.  In  stitching  this  into  place,  fine  silkworm-gut  sutures  were  used, 
and  the  normal  elasticity  of  the  skin  was  taken  advantage  of  to  stretch  the  flap 
carefully  from  one  suture  to  another,  at  the  same  time  making  a  very  careful 
apposition  of  the  edges.  A  second  flap  of  similar  shape  was  cut  still  farther  below 
and  carried  upward  to  fill  in  the  deficiency  made  by  the  removal  of  the  first  flap, 
and  in  like  manner  a  third  was  made  to  take  the  place  of  the  second,  until  the 
incision  was  finally  carried  below  the  collar  line,  where  it  would-  not  be  visible. 
The  disfigurement  of  the  face  was  very  satisfactorily  relieved. 

By  taking  advantage  of  the  skin's  elasticity  and  viability  a  gain  of  about  one- 
hnli  inch  was  made  with  each  flap,  leaving  only  a  narrow  cicatrix  below  the  collar. 

The  dressing  applied  should  make  no  jjressure  over  the  flaps  or  pedicles,  and 
the  position  assumed  should  be  such  as  to  prevent  strain  or  tension. 

Tn  restoring  the  integrity  of  the  lower  eyelid  in  ectropion,  or  the  ala  nasi  after 
syphilitic  ulceration,  this  sliding  procedure  may  be  utilized  to  great  advantage. 

When  there  is  not  sufficient  integument  immediately  about  the  uncovered  sur- 
face to  supply  the  want,  the  flap  may  be  secured  from  some  other  portion  of  the 
body.  Thus  in  extensive  ulcer  with  destruction  of  the  integument  on  the  front 
of  the  leg,  the  author  has  succeeded  in  covering  in  the  surface  by  turning  a  flap 
from  the  posterior  aspect  of  the  opposite  leg,  leaving  a  wide  pedicle,  and  fastening 
the  tfl-o  members  in  an  immovable  position  with  plaster  of  Paris,  so  that  the  flap 
remained  in  its  proper  place  and  free  from  strain.  After  about  ten  days  the  pedicle 
may  be  divided.  In  the  case  of  a  l)oy  who  had  been  seriously  burnecl  at  the  wrist 
and  where  the  cicatricial  contraction  displaced  the  fingers,  deformed  the  hand,  and 
threatened  amputation  of  the  member  by  obstruction  of  the  radial  and  ulnar,  the 
following  operation  was  done  with  success :  All  the  cicatricial  tissue  of  the  wrist 
and  arm  was  dissected  off  down  to  the  tendons  and  bones,  which  were  in  good 
condition.  Two  parallel  incisions,  six  or  seven  inches  long  and  four  inches  apart, 
were  then  made  from  the  ensiform  cartilage  do^\'n  to  the  umbilicus,  and  the  strip 
of  skin  dissected  up  in  the  middle  and  left  attached  at  both  ends.  When  the  small 
amount  of  bleeding  had  been  arrested,  the  hand  was  slid  beneath  this  flap,  the 
under  surface  of  which  was  held  in  contact  with  the  raw  surface  by  stitching  the 
edges  together  with  silk.  A  sterile  dressing  was  applied,  and  the  hand  and  arm 
held  immovable  by  adhesive  plaster  (Fig.  807).  On  the  tenth  day  the  strip  of 
skin  was  divided  above  and  below,  and  the  cufl:  of  skin  folded  around  the  wrist 
and  stitched  in  position.  This  procedure  has  been  repeated  in  a  number  of  cases, 
and  always  with  gratifying  success.  In  all  cases  of  transplanting  skin  no  more 
of  the  subcutaneous  tissue  should  be  lifted  with  the  integument  than  is  necessary 
for  the  vitality  of  the  flap.  .  In  short  flaps  a  very  thin  dissection  may  be  made. 
Near  the  pedicle  a  good  deal  of  tissue  should  be  left  to  insure  the  safety  of  the 
blood  vessels. 

When  sliding  cannot  be  made,  the  method  next  in  order  of  preference  is  trans- 
plantation en  masse.  In  removing  a  piece  of  integument  either  from  the  patient's 
own  body  or  from  that  of  another  person,  it  is  advisable  not  to  attempt  the  transfer 
of  a  large  piece  unless  the  skin  to  be  transplanted  has  been  removed  in  the  course 
of  an  operation.  In  covering  over  large  denuded  areas  after  operation  for  the 
removal  of  cancer  of  the  breast,  or  in  repairing  the  injury  resulting  from  extensive 
burns,  the  superfluous  skin  removed  from  healthy  subjects  in  operations  for  hernise, 
circumcisions,  etc.,  may  be  successfully  utilized  as  grafts.     As  soon  as  removed. 


BURNS,   SCALDS,    SKIN-GRAFTING,   FROSTBITE,   ETC. 


777 


the  pieces  should  be  placed  in  warm  normal  salt  solution  (110°  P.)  until  they 
are  laid  upon  the  raw  or  granulating  surface.  As  a  rule,  pieces  about  an  inch 
square  give  the  greatest  satisfaction,  although  smaller  bits  may  be  employed.  The 
piece  to  be  transferred  should  be  stretched  over  the  finger  in  the  salt  solution  and 
every  vestige  of  fat  or  loose  connective  tissue  trimmed  off  with  a  curved  scissors 
or  sharp  knife  until  it  is  so  thin  that  little  remains  but  the  epidermis,  the  Mal- 
pighian  layer,  and  a  film  of  the  corium  or  connective-tissue   substratum.     The 


Fig.  807.— One  of  th( 


:j[  tr;iiispluntatioii  fniiu  the  abdomen  to  the 


surface  upon  which  the  graft  is  to  be  laid  should  be  rendered  aseptic  and  dry,  and 
if  there  are  granulations,  and  these  are  rich  and  exuberant,  they  should  be  trimmed 
with  the  scissors  twenty-four  hours  before  the  transplantation  is  made,  and  treated 
with  a  one-per-cent  solution  of  picric  acid.  This  application  may  have  to  be  made 
several  times  before  the  surface  is  in  proper  condition.  When  the  larger  trans- 
planted sections  are  applied,  three  or  four  fine  chromicized  catgut  sutures  should 
be  inserted  in  order  to  hold  them  immovably  in  place,  since  any  shifting  of  position 
is  fatal  to  success.  When  the  skin  is  intentionally  removed  for  transplanting,  it 
should  be  sliced  off  with  a  razor  or  dissected  in  thin  sections. 

Dr.  J.  H.  Girdner  has  demonstrated  that  pieces  of  skin  taken  from  a  healthy 
subject  six  hours  after  death  by  accident,  "  cut  into  a  great  many  small  pieces  and 
laid  upon  a  healthy  granulating  surface,  will  become  revitalized." 

Prof.  Ernest  Laplace  recommends  the  following  modification  of  the  method 
of  Thiersch  ^ :  The  exposed  surface  covered  with  granulations  is  treated  with  a 
one-per-cent  solution  of  picric  acid  for  a  day  or  two,  until  it  assumes  a  thoroughly 
healthy  red  and  dry  condition.  Grafts  are  then  transplanted  to  it,  covering  it 
completely  after  Thiersch's  method.  A  single  layer  of  gauze  is  applied  carefully 
over  the  parts,  projecting  about  an  inch  beyond  the  granulating  surface.     It  is 

1  "Am.  Jr.  of  Clin.  Med.,"  March,  1907. 


778  BURNS,   SCALDS,    SKIN-GRAFTING,   FROSTBITE,   ETC. 

maintained  in  position  by  plaster  straps  along  the  edges  of  the  wound.  This  gauze 
protects  the  wound,  but  does  not  interfere  in  the  least  with  the  evaporation  of  the 
serum,  which  nmst  necessarily  exude  from  the  surface.  As  a  result,  a  little  scab 
forms  about  the  edges  of  the  grafts,  no  secretion  results,  and  the  grafts  adhere 
and  take  root  in  the  granulating  surface.  Care  must  be  taken,  however,  that 
nothing  comes  in  contact  with  the  surface  for  fear  of  dislodging  the  grafts. 

"  A  shield  must  be  improvised  of  such  size  and  construction  as  to  prevent  any 
possibility  of  the  sheet  or  binder  touching  the  affected  parts. 

"  It  is  remarkable  how  little  secretion  takes  place  under  these  circumstances  ;• 
and  therefore  how  little  the  de\elopment  of  the  growth  of  the  graft  is  interfered 
with." 

The  method  of  Thiersch  is  as  follows :  The  surface  from  which  the  skin-grafts 
are  to  be  taken  should  be  thoroughly  shaved,  scrubbed  with  soap  and  water,  the 
skin  follicles  cleansed  with  ether,  then  thoroughly  mopped  with  a  1-500  mercuric- 
chloride  solution,  and  again  with  normal  salt  solution  ^  to  remove  the  mercury, 
and  the  place  covered  with  a  dressing  wet  with  the  salt  solution.  In  some  in- 
stances, such  as  superficial  burns  or  ulcers,  especially  where  careful  treatment  has 
kept  the  granulating  surfaces  aseptic,  and  even  in  cases  which  have  become  foul 
and  then  thoroughly  cleansed,  the  grafts  may  take  hold  and  live,  but  it  is  advisable 
to  remove  with  the  curette,  or  preferably  with  the  knife,  the  edges  of  the  ulcer 
down  to  the  healthy  skin,  together  with  the  granulations  which  are  shaved  off  with 
the  knife,  or  scraped  if  the  sharp  spoon  is  employed.  The  bleeding  surface  should 
be  carefully  sterilized  by  normal  salt  solution,  which  should  be  boiled  just  before 
using,  and  haemorrhage  stopped  by  pressure  with  sterilized  gauze  for  the  double 
reason  that  the  escaping  blood  would  lift  the  grafts  up  from  the  prepared  bed, 
while  a  coagulum  would  invite  infection.  Grafts  or  flakes  of  skin,  including  chiefly 
the  epithelial  layers,  arq  shaved  off  with  a  very  sharp,  broad-bladed  knife,  long 
enough  to  permit  a  free  sawing  movement,  which  facilitates  the  cutting  of  thin 
sections.  Moisten  the  blade  in  salt  solution,  make  the  skin  tense,  and  remove  large, 
thin  flakes.  From  half  an  inch  to  an  inch  in  width  and  from  two  to  three  inches 
or  more  in  length  is  a  convenient  size  for  lifting  and  transplanting.  These  grafts 
include  the  epithelia  and  the  papillary  layer;  even  a  film  of  the  connective-tissue 
stroma  of  the  corium  will  not  interfere  with  growth.  Keep  the  graft  moist  all  the 
time  with  salt  solution  and  carry  it  directly  to  the  surface  to  be  covered,  sliding 
it  from  the  razor  to  its  proper  place  on  the  wound,  bottom  side  down.  As  the 
tendency  of  these  grafts  is  always  to  roll  toward  their  raw  surface,  each  should  be 
gently  imfolded  with  dull  forceps  or  a  probe  and  laid  flat  down.  Piece  after  piece 
should  be  applied  and  carefully  adjusted  along  the  edges  of  the  wound  and  to  each 
other  like  paving  stones  until  the  entire  surface  is  floored.  The  whole  is  then 
covered  over  vrith  thin  strips  of  rubber  tissue  about  half  an  inch  in  width.  The 
rubber  tissue  should  be  sterilized  in  mercuric-chloride  solution,  washed  off  in  salt 
solution,  and  shaken  before  being  applied.  It  is  well  enough  in  applying  these 
strips  to  leave  here  and  there  a  little  crevice  or  crack,  through  which  any  transuda- 
tion may  escape.  Directly  over  the  strips  a  layer  of  sterile  gauze,  absorbent  cotton, 
a  large  piece  of  rubber  tissue,  and  over  all  a  bandage  with  light  compression. 

In  from  thirty-six  to  forty-eight  hours  the  dressing,  may  be  removed,  not  dis- 
turbing the  protective,  however,  for  from  one  to  two  weeks.  Upon  removing  the 
protective,  it  should  be  carefully  taken  off  so  as  not  to  lift  the  grafts ;  if  suppura- 
tion has  occurred,  the  fluid  should  be  absorbed  with  gauze  mops  or  cotton  wet  with 
salt  solution,  the  parts  being  touched  very  lightly. 

When  the  condition  demands,  several  thicknesses  of  grafts  may  be  laid,  one 
over  the  other,  at  the  original  or  a  subsequent  operation.  Some  operators  employ 
Esmarch's  bloodless  method  when  an  extremity  is  involved,  as  it  prevents  bleeding 
and  saves  time  in  operating.  The  constriction  is  not  removed  until  the  operation 
is  completed  and  the  dressing  applied,  the  compression  of  the  flnal  roller  preventing 
oozing. 

The  more  remote  changes  in  Thiersch  skin-grafts  have  been  studied  by  Gold- 
mann  ("Annals  of  Surgery,"  vol.  xix,  1894),  who  says  that  cell  proliferation  in 

'  Normal  salt  solution,  six  tenths  of  one  per  cent,  approximately  gr.  ijss.  to  water  Sj- 


BURNS,   SCALDS,   SKIX-GR.AFTIXG,   FROSTBITE,    ETC.  779 

the  middle  layer  of  the  epidermis  is  vigorous,  and  this  continues  two  or  three 
months;  the  outer  layer  is  cast  off  more  rapidly  than  in  normal  skin,  due  to  the 
novel  and  insufficient  nutrition,  the  exfoliation  ceasing  when  the  new  vessels  are 
sufficiently  formed  beneath  the  skin.  Mobility  of  the  new  skin  in  ease  of  small 
•defects  was  noticed  in  about  eight  weeks,  longer  in  larger  wounds.  He  also  demon- 
strated in  skin  thus  developed  elastic  fibers  and  connective  tissue;  sensation  is 
restored  slowl)',  traveling  from  the  periphery  to  the  center,  showing  that  the  new 
skin  from  Thiersch  grafts  requires  from  two  to  eight  months  to  become  fully 
formed.  It  is  a  matter  of  importance  that  all  dense  cicatricial  tissue,  as  after 
deep  burns,  should  be  dissected  away,  since  grafts  do  not  yield  satisfactory  results 
when  planted  upon  scar  tissue. 

Dr.  Z.  J.  Lusk  ^  reports  the  successful  use  of  the  epithelium  raised-  by  blisters 
in  successfully  covering  in  large  granulating  surfaces  after  burns. 

Defects  of  hairy  surfaces  can  be  covered  with  grafts  of  hair-growing  skin.  Dr. 
P.  A.  Morrow  has  successfully  planted  grafts  which  included  the  entire  thickness 
of  the  skin  and  scalp,  using  a  punch  or  trephine  to  cut  out  buttons  of  material 
and  accurately  fitting  them  to  depressions  or  beds  in  the  scar  tissue.  In  some 
instances  the  hairs  reappeared,  though  not  as  luxurious  in  growth  as  before. 

Destruction  of  the  skin  by  acids  or  alkalies  require  no  special  consideration 
heyond  the  adoption  of  measures  to  neutralize  the  escharotic  action  in  the  parts 
involved.  For  covering  the  denuded  area  the  method  Just  given  for  ordinary 
burns  and  scalds  is  employed.  Carbolic  acid  is  best  neutralized  b}'  the  application 
of  alcohol,  while  the  acids  and  alkalies  are  in  general  antagonized  for  chemical 
neutralization. 

Frostbite. — The  effect  of  prolonged  and  extreme  cold  upon  the  animal  tissues 
is  to  cause  occlusion  of  the  capillaries,  loss  of  sensation,  and  death  by  gangrene. 
.The  treatment  is  to  attempt  a  gradual  restoration  of  the  circulation  by  friction 
in  a  low  temperature.  A  part  of  the  body  benumbed  by  cold  should  never  be  sub- 
mitted suddenly  to  a  high  temperature,  but  should  be  bathed  and  nibbed  in  snow 
or  cold  water,  the  temperature  of  which  is  slowly  elevated.  Wlien  gangrene  results, 
amputation  is  demanded  after  the  line  of  demarcation  is  established. 

Furuncle. — A  boil  is  a  circumscribed  infection,  commencing  usuallj'  in  the  hair 
follicles  and  sebaceous  glands,  and  extending  to  the  subcutaneous  tissues.  It  is 
caused  by  the  lodgment  in  a  suitable  nidus  of  pyogenic  bacteria.  The  proliferation 
of  this  organism  produces  inflammation,  and  suppiiration  with  localized  necrosis. 
A  boil  may  be  differentiated  from  a  carbuncle  by  the  more  acute  inflammatory 
process  of  the  furuncle,  with  almost  always  a  single  point  of  suppuration,  well- 
defined,  limited  redness,  and  the  acute  character  of  the  pain.  In  carbuncle  the 
inflammation  extends  more  widely  and  deeper,  the  induration  is  greater,  there  are 
several  points  of  suppuration,  and  the  febrile  sjTuptoms  more  appreciable.  The 
treatment  looks  to  an  early  relief  from  tension  in  the  integument,  and  the  sepa- 
ration and  discharge  of  the  slough  and  pus.  Incision  should  be  performed  at  once. 
The  judicious  use  of  cocaine  hypodermically  will  prevent  pain,  and  much  suffer- 
ing will  be  avoided  by  prompt  action.  The  application  of  cold  or  heat  is  at  times 
useful.  Poultices  are  almost  universally  employed  to  soften  the  skin  and  hasten 
the  discharge  of  the  dead,  tissue.  It  is  in  general  not  advisable  to  wait  for  so  slow 
a  process.  After  incision  a  warm,  moist  sublimate  flaxseed  poultice  or  dressing 
should  be  applied,  and  continued  until  a  cure  is  effected. 

The  constitutional  treatment  should  be  directed  to  the  correction  of  any  exist- 
ing dyscrasia.  The  preparations  of  iron  and  mercury  are  the  best  general  remedies. 
Tonics,  good  food,  regulation  of  the  alimentary  apparatus,  and  good  hygiene  are 
essential.  Sulphide  of  calcium  (gr.  jV  to  |-  three  or  four  times  a  day),  arsenic, 
the  iodides,  cod-liver  oil,  with  the  hjq^ophosphites  of  lime  and  soda,  are  among  the 
remedies  most  recommended. 

Carbuncle. — This  disease — which,  as  Prof.  A.  E.  Eobinson  -  remarks,  has  been 
misnamed  "  anthrax  " — is  an  infectious  inflammatory  process  of  a  low  order,  in- 
volving chiefly  the  skin  and  the  connective  tissues  immediatelj'  beneath  it,  and  in 

'  "Medical  Record,"  Becember  7,  1895. 
^  "Manual  of  Dermatology,"  1884. 


780  BURNS,    SCALDS,    SKIN-GRAFTING,   FROSTBITE,   ETC. 

some  instances  extending  into  the  deeper  organs.  Anthrax  or  malignant  pustule 
is  not  in  its  incipieney  a  suppurative  disease;  carbuncle  is  always  so.  The  process 
is  akin  to  that  of  furuncle,  though  indicative  of  a  more  depraved  condition  of  the 
tissues.  AVhile  the  infection  in  furuncle  is  single,  as  a  rule,  in  carbuncle  there  are 
two  or  many  centers  of  infection  with  pyogenic  bacteria,  which  may  or  may  not 
o-radually  coalesce  in  one  wide  area  of  inflammation  and  necrosis.  When  this 
occurs  the  inflamed  area  breaks  down  in  several  places,  giving  discharge  to  pus 
(usually  in  small  quantity),  as  well  as  to  dead  tissue.  It  is  apt  to  occur  as  a 
complication  of  the  same  diseases  with  which  furuncles  are  seen — diabetes  mellitus, 
tuberculosis,  etc. — and  in  parts  of  the  economy  subjected  to  more  than  ordinary 
irritation,  as  the  back  of  the  neck,  where  the  collar  presses,  and  in  the  gluteal 
region. 

The  symptoms  of  this  afEection  are  a  sense  of  malaise,  loss  of  appetite,  headache, 
fever,  varying  in  intensity,  which  is  followed  by  or  accompanied  with  a  deep-seated 
and  severe  pain  in  and  about  the  local  expression  of  the  disease.  The  skin  at  this 
point  becomes  tense,  injected,  doughy  to  the  touch,  throbbing,  and  painful;  the 
epidermis  becomes  lifted  at  various  spots  in  the  inflamed  area,  vesicles  form, 
localized  gangrene  occurs,  and  the  dead  matter  sloughs  away.  Not  infrequently 
the  necrotic  process  rapidly  extends  through  the  areolar  tissue  beneath  the  skin 
some  time  before  the  integument  breaks  down.  The  extent  of  necrosis  varies  under 
different  conditions,  and  may  be  general  or  limited.  The  constitutional  symptoms 
are  determined  by  the  amount  of  septic  absorption  and  the  degree  of  pain  ex- 
perienced. 

The  process  of  repair  is  by  granulation,  the  development  of  an  embryonic 
tissue  which  advances  from  the  sides  and  bottom  of  the  cavity  as  the  slough  is 
carried  away.  As  to  the  length  of  time  carbuncle  may  last,  nothing  positive  can 
be  stated.  Usually  from  three  to  seven  weeks;  at  times,  when  the  process  is  sub- 
acute, several  months. 

The  prognosis  depends  upon  the  condition  of  the  patient,  the  age,  the  location 
and  extent  of  the  lesion,  and  the  ability  of  the  capillaries  and  lymphatics  to  resist 
septic  absorption.  Occurring  in  diabetes  or  any  dangerous  malact}',  it  hastens  a 
fatal  issue.  Situated  iipon  the  face,  the  gravity  of  the  prognosis  is  increased. 
This  is  in  great  part  due  to  the  intense  pain  which  follows  an  invasion  of  that 
part  of  the  body  in  which  the  trifacial  nerve  is  distributed.  When  located  on  the 
thorax,  the  pleura  may  become  involved,  thereby  causing  a  grave  complication. 

The  treatment  should  look  to  the  immediate  improvement  of  the  patient's 
vitality  by  all  available  means.  The  local  treatment  should  be  directed  to  the 
removal  of  the  entire  area  of  infection  at  an  early  date.  In  this  way  alone  can 
the  great  danger  of  septictpmia  be  averted,  or  the  relief  of  tension  by  incisions, 
and  the  discharge  of  septic  matter. 

Poultices,  if  employed,  should  be  made  with  1-5000  sublimate  solution,  as  here- 
tofore directed. 

Ulcers. — An  ulcer  is  the  result  of  molecular  death  in  the  integument  or  mucous 
membrane,  and  the  underlying  areolar  or  submucous  tissue,  and  is  due  to  the 
presence  of  one  or  several  varieties  of  pathogenic  bacteria.  The  arrest  of  nutrition 
which  these  organisms  produce  may  be  local,  as  in  the  ulcer  of  chancroid,  or  gen- 
eral, as  in  the  late  manifestations  of  syphilis,  scorbutus,  etc.  Occiirring  with  a 
dyscrasia,  ulcers  are  even  tlien  more  apt  to  occur  in  parts  of  the  body  subjected 
to  abnormal  interference  with  the  circulation. 

Specific  ulcers  will  be  considered  with  the  diseases  of  -which  they  form  a  part. 
Ulcers  may  be  divided  into  two  clinical  groups — the  active  and  indolent.  In  one, 
the  material  for  repair  is  in  excess;  in  the  other  it  is  deficient.  One  of  the  most 
frequent  seats  of  ulcer  is  upon  the  anterior  aspect  of  the  tibia  at  its  middle  and 
lower  portions.  They  occur  usually  in  the  aged,  and  chiefly  among  the  poorly  fed 
and  lalDoring  classes,  where  the  erect  posture  is  of  necessity  maintained  for  many 
successive  hours.  Varicosities  of  the  veins  of  the  lower  extremities  must  be  put 
down  as  a  common  cause  of  non-specific  ulcers. 

The  treatment  of  ulcers  must  be  directed  to  the  cause  of  the  tissue  destruction. 
In  varicosities  the  integrity  of  the  circulation  should  be  restored  by  supporting  the 


ULCERS— GANGRENE 


781 


vessels  by  mechanical  means,  or  relieving  the  overpressure  bj^  position.  For  the 
former  the  elastic  stocking,  properly  adjusted,  is  invaluable.  Martin's  elastic  band- 
age is  an  excellent  apparatus,  but  requires  considerable  care  in  its  even  and 
skillful  application.  'When  neither  of  these  methods  is  available,  pressure  may  be 
successfully  employed  by  means  of  flannel  or  muslin  bandages.  An  elevated 
position  of  the  foot  and  leg  should  be  maintained  in  all  ulcers  of  the  lower 
extremities. 

An  indolent  ulcer  demands  stimulation.     This  may  be  effected  by  irrigation 
from  a  fountain  syringe  sufficiently  elevated  to  give  strong  pressure,  with  normal 
salt  solution  at  120°   F.,  for  ten  or  fifteen  minutes  twice 
daily.    A  wet  gauze  dressing  and  tight  roller  should  be  ap-  \  j 

plied.     Supporting  the  edges  of  the  sore  with  well-adjusted  \  J 

strips  of  diachylon  plaster  is  also  a  commendable  practice.  |    \^  ] 

The  strips  should  be  cut  about  three  fourths  of  an  inch  wide,  |  ^     ^J 

and  crossed  in  a  spiral  manner  (Fig.  808). 

Irritable  iileers  require  rest  and  soothing  applications. 
One  of  the  most  satisfactory  preparations  for  the  treatment 
of  all  forms  of  ulcers,  granulating  surfaces,  incised  accumu- 
lations of  pus,  septic  wounds  of  all  kinds,  burns,  etc.,  where 
absorption  of  moisture  is  desired,  is  the  halsam-oil  mixture 
first  employed  by  Prof.  W.  W.  Van  Arsdale  in  188-t.  It 
forms  an  excellent,  slightly  astringent,  and  unirritating 
dressing.  For  ordinary  use  it  suffices  to  cover  the  surface 
with  a  mat  of  absorbent  gauze,  painting  it  over  thickly  with 
a  brush.  Enough  gauze  should  be  used  to  absorb  the  quan- 
tity of  exudate  for  the  time  it  is  to  be  left  on.  Over  the 
absorbent  gauze,  cotton  batting  is  laid,  over  this  rubber  tis- 
sue or  oil-silk  protective,  and  a  light  bandage  over  all.  When 
it  can  be  obtained,  the  sterile  preparation  should  be  used. 
It  is  made  by  submitting  castor  oil  for  at  least  two  hours 
to  a  temperature  of  160°  C.  (3"20°  F.).  A  special  chemical 
thermometer  is  necessary  for  this  purpose.  The  sterilized 
oil  should  then  be  jDoured  into  bottles  taken  out  of  boiling 
■water,  immediately  corked  with  rubber  stoppers  similarly 
sterilized.  The  sterile  oil  will  sutBce  without  the  addition 
of  the  Peruvian  l^alsam,  but  I  usually  prefer  to  add  this,  and 
this  must  be  done  as  the  oil  is  poured  out  at  the  time  of 
using.  Balsam  cannot  be  heated  'svithout  destroying  its 
value.  Twenty  minims  of  balsam  to  the  ounce  of  castor  oil 
is  the  proportion.     For  infected  wounds,  while  the  aseptic  Fig.  sus. 

preparation  is  ahvays  to  be  preferred,  3'et,  when  it  cannot  be 

obtained,  the  ordinary  cold-pressed  castor  oil  can  be  used,  and  the  balsam  added  in 
the  same  proportion  as  given.  The  constitutional  treatment  of  all  patients  suffering 
from  ulcers  is  of  first  importance.  Ulcers  wdiich  have  destroyed  large  areas  of 
integument  cannot  be  cured  without  the  transplantation  of  skin. 

Gangrene  is  death  of  a  part  of  the  body  from  the  gradual  or  sudden  arrest  of 
its  nutrition.  The  term  is  usually  applied  to  the  process  of  mortification  in  the 
softer  structures.  The  analogous  condition  of  bone  is  called  necrosis.  Animal 
tissues  have  two  modes  of  dying — the  one  is  molecular,  or  death  by  granular  meta- 
morphosis, in  which  no  trace  of  the  anatomical  or  histological  properties  of  the 
tissues  remains ;  the  other  is  death  in  httlh,  in  which,  although  the  tissues  deprived 
of  life  undergo  rapid  decomposition  and  ultimate  disintegration,  they  retain  for 
a  time  something  of  their  original  form.  It  is  to  denote  this  last  variety  of  tissue 
death  that  the  term  gangrene  is  employed. 

There  are  three  varieties — namely,  the  acute,  or  moist;  the  chronic,  senile,  or 
dry;  and  the  contagions,  phagedenic,  or  hospital  gangrene. 

Acute  Gangrene. — The  chief  cause  of  moist  gangrene  is  the  sudden  obstruction 
of  the  afferent  or  efl^erent  vessels  of  a  part.  AVhether  the  artery  is  alone  occluded, 
as  by  an  embolus,  the  ligature,   or  an  accidental  solution  of  its   continuity;   or 


782  GANGRENE 

whether  the  venous  current  is  arrested  while  the  artery  is  permeable;  or  whether 
the  arrest  in  both  systems  is  simultaneous,  as  by  the  constriction  of  a  finger  with 
a  ring,  or  in  the  case  of  a  strangulated  hernia — the  part  beyond  the  lesion  is 
charged  with  blood  which,  arrested  in  its  flow,  loses  its  -vitality  and  takes  an  early 
part  in  the  work  of  decomposition  which  ensues. 

When  an  artery  is  obliterated,  the  vitality  of  the  tissues  on  the  peripheral  side 
of  the  occlusion  depends  upon  the  integrity  of  the  collateral  circulation.  If  the 
occlusion  is  gradual,  the  enlargement  of  the  collateral  branches  is  usually  sufficient 
to  carry  the  necessary  supply  of  blood.  There  is  scarcely  a  point  in  the  arterial 
system  where  a  collateral  route  may  not  be  established,  provided  the  process  of 
obliteration  is  not  too  sudden,  and  the  blood  has  not,  by  reason  of  constitutional 
disturbance,  been  deprived  of  its  nutritive  properties.  When  these  conditions  do 
not  prevail,  mortification  ensues  with  a  rapidity  proportionate  to  the  partial  or 
total  arrest  of  nutrition.  Pallor  is  the  immediate  and  earliest  symptom  of  arterial 
obstruction,  followed  by  coldness  of  the  skin  and  pain,  which  is  usually  not  acute. 
Beginning  in  the  parts  farthest  removed  from  the  heart,  the  phenomena  of  death 
extend  toward  the  center  until  the  border  line  is  reached  between  the  living  and 
dying  tissues.  Congestion  and  swelling  are  not  marked  features  of  arterial  gan- 
grene. The  normal  contractility  of  the  tissues,  an  elevated  position,  and  the  influ- 
ence of  the  return  current  in  veins  vsdth  which  those  of  the  j)art  involved  commu- 
nicate, tend  to  empty  the  vessels  beyond  the  seat  of  obstruction.  Of  necessity, 
however,  a  considerable  quantity  of  blood  remains,  and  when  its  flow  is  arrested 
its  function  is  lost,  and  its  elements  join  in  the  general  decomposition  which  ensues. 
In  the  putrefactive  process,  gases,  notably  sulphuretted  hydrogen  and  those  result- 
ing from  decomposition  of  the  fatty  tissue,  are  evolved,  and  the  coloring  matter 
of  the  blood  is  liberated.  Myosin,  the  albuminous  principle  of  muscle,  coagulates, 
giving  a  temporary  sense  of  rigidity,  and  the  serum  which  remained  in  the  vessels 
undergoes  transudation,  and  is  generally  distributed  among  the  tissues.  Cutaneous 
sensibility  is  soon  lost,  and  the  momentary  pallor  gives  way  to  a  grayish  hue,  which 
deepens  into  a  greenish-black  color.  Though  not  so  marked  as  in  the  condition 
resulting  from  venous  occlusion,  the  skin  and  subcutaneous  tissues  become  infil- 
trated with  fiuid  and  gases,  giving  a  doughy  feel  upon  pressure,  and  at  times  the 
peculiar  crackling  of  emphysema.  Serum  and  hydrogen,  in  the  effort  to  escape, 
may  at  various  points  be  caught  under  the  impervious  epidermis,  which  is  lifted 
up  into  blisters.  In  resisting  gangrene,  certain  tissues  retain  their  anatomical 
features  longer  than  others.  Bone  and  tendon  are  slow  to  disappear,  and  at  times 
the  arteries  will  resist  destructive  change,  when  the  tissues  through  which  they  pass 
have  been  entirely  destroyed. 

When  once  inaugurated,  mortification  extends  to  a  point  where  nutritive  changes 
in  the  tissues  are  sufficiently  active  to  resist  death.  The  line  between  this  zone 
and  the  blackened  slough  is  called  the  line  of  demarcation. 

The  line  of  demarcation  is,  as  a  rule,  irregular  in  extent.  When  a  part  has  been 
constricted  until  death  ensues,  the  line  of  separation  may  be  a  well-defined  circum- 
ference; but  in  arterial  occlusion  this  is  a  rare  exception. 

Accompanying  the  phenomena  above  detailed,  shoals  of  organisms  proliferate 
in  the  tissues  involved,  and  rapid  putrefactive  changes  occur;  the  soft  parts  drop 
away  in  offensive  sloughs,  leaving  the  bone  projecting  from  the  stump  of  this 
natural  amputation. 

The  symptoms  of  gangrene  from  venous  obstruction  differ  in  some  essential 
features  from  mortification  after  arterial  occlusion. 

Engorgement  is  more  marked,  since  the  cardiac  and  arterial  forces  are  at  work 
overdistending  the  tissues  beyond  the  obstruction  with  blood.  The  skin  is  of  pur- 
plish hue  from  the  start,  pain  is  intense,  the  swelling  great,  and,  until  coagulation 
is  accomplished,  there  is  a  sense  of  throbbing  in  the  affected  part.  There  is  at 
first  an  elevation  of  temperature,  which,  however,  is  of  short  duration.  Blisters 
are  more  numerous,  and  putrefaction  occurs  more  rapidly. 

Gangrene  from  combined  arterial  and  venous  occlusion  has  its  type  in  a  stran- 
gulated hernia,  or  in  mortification  of  a  finger  which  has  been  constricted  by  a  ring. 
In  this  variety,  arrest  of  the  circulation  and  coagulation  of  the  blood  are  more 


GA^'GREXE  783 

abrupt.     The  Temaining  features  of  this  form  of  mortification  do  not  differ  mate- 
rially from  those  heretofore  described. 

Treatment  of  Moist  Gangrene. — ^^'hen  an  artery  is  obstructed,  the  first  indica- 
tion is  to  remove  the  obstruction.  Failing  in.  this,  to  promote  the  establishment 
of  a  collateral  circulation,  and  to  maintain  the  temperature  of  the  part  affected. 
The  position  of  the  limb  should  be  such  that  pressure  upon  the  structures  through 
•n"hich  the  anastomotic  branches  run  should  be  avoided.  Cotton  batting  should  be 
carefulh'  ■nTapped  about  the  part  to  the  thickness  of  several  inches,  and  oil  silk  or 
rubber-tissue  protective  wrapped  around  this.  Xo  pressure  by  bandages  should  be 
employed.  The  application  of  hot  water,  directly  or  by  bottles,  is  to  be  deprecated, 
for  heat  is  now  known  to  produce  capillary  contraction.  The  extremity  may  be 
slightly  lowered,  in  order  to  invite  the  flow  of  blood,  although  care  should  be  taken 
to  prevent  obstruction  of  the  veins. 

While  these  local  measures  are  being  adopted,  eertata  constitutional  remedies 
may  be  indicated.  These  relate  primarily  to  cardiac  stimulation,  opium  to  relieve 
pain  and  palliate  shock,  and  to  an  early  improvement  in  the  nutritive  quality  of 
the  blood ;  the  administration  of  alcohol  and  beef  juice,  and  the  careful  combination 
of  those  articles  of  food  which  are  acceptable  to  the  patient,  and  are  known  to  be 
rich  in  nitrogen.  Any  intercurrent  disease  or  complication  will  indicate  a  modi- 
fication of  the  treatment  to  suit  the  emergency.  As  death  progresses  and  the 
sloughing  begins,  all  structures  which  can  be  removed  easily  and  without  pain 
should  be  cut  away  with  dressing  forceps  and  scissors.  Iodoform,  freely  sprin- 
kled over  the  sloughs,  will  prove  a  good  deodorizer,  or  the  dead  part  may  be 
kept  wrapped  in  sublimate  gauze,  soaked  in  1-2000  solution,  and  kept  moist  by 
protective. 

Hsemorrhage  is  rare  in  this  varietv'  of  gangrene,  yet  when  it  does  occur  it  de- 
mands the  ligature  or  compression. 

The  treatment  of  gangrene  where  the  vein  alone  is  obstructed,  in  which,  as  has 
been  stated,  the  condition  of  engorgement  is  extreme,  demands  the  elevation  of 
the  part  in  order  to  facilitate  the  escape  of  blood  through  the  venous  channels. 
The  tension  of  the  part  may  at  times  demand  incisions  through  the  deep  fascia. 
The  same  precautions  as  to  temperature  must  be  taken  here.  The  constitutional 
treatment  will  be  less  stimulating,  yet  supporting,  and  the  local  management  of 
the  dead  part  will  be  the  same  as  given. 

Wlien  all  the  vessels  are  subjected  to  pressure,  it  is  essential  to  relieve  the  con- 
striction as  early  as  possible.  However,  the  vitality  of  an  organ  seemingly  dead 
should  not  be  despaired  of,  since  restoration  of  function  after  prolonged  strangu- 
lation is  occasionally  witnessed.  When,  as  in  phlegmonous  or  other  inflammation, 
the  tension  is  so  extreme  that  gangrene  is  threatened  by  pressure  of  the  exudation 
upon  the  capillaries  or  larger  vessels,  free  incisions  should  be  made,  parallel  with 
the  general  direction  of  the  vessels,  and  of  suiScient  depth  and  number  to  relieve 
the  tension.  Wlien,  as  in  threatened  gangrene  of  a  finger,  the  swelling  is  severe, 
increasing,  as  it  does,  the  tension  of  the  organ  and  its  own  destruction,  incisions 
are  also  demanded,  and  may  prevent  mortification  before  the  constricting  body 
is  removed. 

Dry  or  senile  gangrene  is  a  disease  of  malnutrition,  the  immediate  cause  of 
which  is  a  gradual  diminution  of  an  already  impoverished  blood  supply,  due  to 
a  more  or  less  complete  occlusion  of  the  terminal  arterioles.  With  the  extremely 
rare  exceptions  caused  by  toxic  ingesta  (ergot  of  rye,  etc.),  it  is  a  disease  of  old 
age,  and  the  chronic  arteritis  which  ultimately  causes  the  death  of  tissue  follows 
in  the  train  of  syphilis,  rheumatism,  gout,  alcoholism,  and  nephritis.'  In  all 
probabilitj'  alcohol,  syphilis,  and  diabetes  are  the  chief  factors. 

The  inflammatory  changes  in  the  blood  vessels  which  conduce  to  senile  gangrene 
are  connected  with  the  intima,  which,  as  a  result  of  cell  proliferation,  together 
with  the  incidental  deposit  of  fibrin  upon  the  roughened  surfaces  of  the  lining 
membrane,  becomes  greatly  thickened,  impinges  upon  the  lumen  of  the  vessel,  and 
finally  occludes  it.  In  syphilis  the  changes  in  the  vessels  are  more  rapid  than  in 
alcoholic  arteritis,  and  are  usually  first  observed  in  the  brain,  and  in  this  condition 
calcification  is  not  so  apt  to  occur  as  in  the  endarteritis  which  is  a  part  of  the 


784  GANGRENE 

alcoholic,  rheumatic,  or  gouty  diathesis.^  The  process  of  occlusion  is  almost  always 
gradual,  and  the  signs  of  commencing  death  are  usually  first  noticed  in  the  lower 
extremities,  wliere,  by  reason  of  gravitation  and  remoteness  from  the  heart,  the 
circulation  is  naturally  retarded.  The  occlusion  is  at  times  hastened  by  trauma- 
tism or  some  accidental  inflammatory  process  establislied  in  a  limited  area  of  the 
wall  of  an  artery  already  the  seat  of  chronic  arteritis. 


•> 


Fig.  809. — Arteritis  with  primary  calcification.  Section  from  human  radial  artery,  showing  at  B 
primary  calcification  of  the  media,  c.  A,  the  intima  comparatively  unchanged.  (Drawn  from 
specimens  prepared  by  Dr.  W.  L.  Wardwell,  at  Conlieim's  Laboratory.  Magnified  about  350 
diameters.) 

Treatment. — The  part  affected  should  be  enveloped  in  cotton  batting,  covered 
with  oil  silk  or  protected  and  placed  in  the  position  of  least  discomfort  to  the 
patient.  The  pressure  upon  the  limb  as  it  rests  in  l^ed  should  be  equably  distrib- 
uted. The  general  condition  of  nutrition  should  be  given  strict  attention.  Tonics, 
mild  stimulation,  and  the  most  nourishing  articles  of  diet,  taking  care  to  keep  the 
alimentary  canal  empty.  No  operative  procedure  is  justifiable  until  a  well-defined 
line  of  demarcation  is  established,  unless  septic  absorption  threatens  the  life  of  the 
patient,  or  unless  pain  is  so  severe  as  to  be  unendurable.  In  j^erforming  amputa- 
tion, in  order  to  insure  asepsis  the  operation  should  be  done  several  inches  away 
from  the  line  of  demarcation,  and  the  least  possible  traumatism  should  1'je  inflicted. 
JSTo  tourniquet  should  be  applied.  The  circulation  can  be  controlled  by  gravitation, 
aided  by  digital  pressure  upon  the  main  artery  at  a ,  2)oint  remote  from  the  line 
of  amiDutation.  When  calcification  of  the  arteries  is  present  it  will  be  advisable  to 
include  in  the  grasp  of  the  ligature  a  certain  amount  of  muscular  or  other  connective 
tissue,  since  the  ligature  is  apt  to  break  or  cut  through.  The  flap  should  be  closed 
with  silkworm-gut  sutures,  not  nearer  than  one  half  inch  from  each  other,  with 
little  wisps  of  catgut  inserted,  so  as  to  insure  drainage.  On  account  of  the  low 
resistance  of  these  tissues  infection  is  apt  to  occur,  followed  by  gangrene  of  the 
flaps. 

1  The  late  Dr.  W.  L.  Wardwell,  of  New  York  City,  in  Conlieim's  Laboratory.  His  experience 
includes  examinations  made  from  twenty-five  cases  at  the  request  of  Conheim,  who  approved 
his  conclusions.  Dr.  Wardwell  says  all  authorities  recognize  a  morbid  change  in  the  arteries 
known  as  calcification,  and  the  majority  look  upon  it  as  a  change  secondary  to  atheroma  or  en- 
darteritis. Few  of  these  recognize  a  primary  calcification  not  dependent  upon  a  preceding  in- 
flammation. This  condition  is,  however,  the  chief  change  in  the  senile  calcification  of  arteries. 
The  microscopic  appearances  of  primary  calcification  are  well  shown  in  Fig.  809. 

Conheim  states  that  in  senile  aterial  calcification  sometimes  the  media,  sometimes  the  interna 
(its  outermost  layer),  is  affected,  and  that  in  them  the  lime  salts  are  deposited. 


CHAPTER    XXXIX 

THE    BLOOD 

HcematoJogy. — A  careful  study  of  the  blood,  especially  as  to  the  percentage  of 
hEemoglobin  which  is  present,  and  the  condition  of  tlie  various  eorjmscular  elements 
and  their  numerical  proportion  to  each  other,  is  of  imjjortance  in  the  treatment 
of  many  surgical  lesions,  and  should  enable  the  surgeon  to  detect  not  only  any 
form  of  ansmia,  but  to  determine  whether  it  is  a  tj^pe  of  blood  impoverishment 
which  can  be  corrected,  or  whether  it  is  of  the  graver  or  more  pernicious  forms 
which  would  either  preclude  an  operation  or,  if  this  is  absolutely  necessary,  would 
enable  him  to  announce  the  gravity  of  the  prognosis. 

In  ordinary  practice  it  is  not  always  essential  to  differentiate  between  a  per- 
nicious anjemia  or  a  leulca?mia,  or  whether  tliis  latter  condition  is  present  in  the 
l}Tnp]iatic  or  splenic-myelogenous  form,  for  the  reason  that  all  of  these  graver 
varieties  call  a  halt  to  operative  measures  when  these  may  be  avoided.  But  the 
ansemia  which  comes  from  malnutrition  or  malaria  or  chlorosis  can  be  positively 
diagnosticated  by  a  careful  blood  technic. 

In  general,  the  resistance  of  the  tissues  may  be  measured  by  the  nearness  of 
the  hfemoglobin  ratio  to  the  normal. 

Normal  blood  contains  approximately  13. .5  of  haemoglobin,  but  for  convenience 
the  normal  amount  is  reckoned  at  100  per  cent. 

A  simple  method  of  determining  this  proportion  is  by  means  of  the  Tallquist 
hsemoglobin  scale,  which  is  suiSciently  accurate  for  ordinary  purposes,  and  has  the 
advantage  of  being  made  quickly  and  without  artificial  light.  It  consists  of  sheets 
of  absorbent  paper  which,  when  stained  with  a  drop  of  blood,  the  redness  or  riclmess 
of  the  stain  is  determined  by  comparison  with  a  fixed  scale  of  colors. 

A  low  percentage  of  hajmoglobin  contra-indicates  the  shock  or  exhaustion  of 
an  antestlietic  and  an  operation.  It  suggests  the  aid  of  the  microscope  in  a  further 
examination  as  to  the  condition  of  the  corpuscular  elements  of  the  blood.  It  is 
advised  by  Mikulicz  never  to  operate  wlien  the  register  of  the  hsemometer  shows 
less  than  35,  and  it  would  2}robably  be  safer  to  ptlace  the  standard  10  or  15  points 
higher.^ 

Under  the  microscope  there  are  observed  the  red  corpuscles  (erytlirocytes),  the 
white  corpuscles  (leucocji:es),  and  the  blood  platelets. 

'  A  more  accurate  method  is  that  employed  with  von  Fleischl's  haemometer,  which  consists 
of  a  metal  stand  resembling  the  stage,  pillar,  and  base  of  a  microscope.  In  the  center  of  the  stage 
is  a  circular  opening,  which  receives  a  circular  cell  or  tube  with  a  glass  bottom  and  which  is  divided 
into  two  equal  compartments  by  a  partition.  Beneath  the  stage  is  a  plaster-of-Paris  disk,  not 
unlike  the  mirror  of  a  microscope  both  as  regards  its  shape  and  position.  In  a  sliding  groove 
beneath  the  stage  a  metal  frame  is  iitted,  which  supports  a  colored  glass  prism,  wedge-shaped  and 
accordingly  deeper  in  color  at  one  end  than  at  the  other.  By  means  of  a  milled  screw  the  prism 
can  be  moved  back  and  forth,  and  at  will  any  portion  of  its  length  can  be  brought  into  view  through 
the  opening  in  the  stage.  When  the  cell  is  in  its  place  on  the  stage,  the  prism  can  be  seen  through 
one  of  its  compartments,  while  the  white  surface  of  the  plaster  disk  is  seen  through  the  other. 
For  use,  both  these  compartments  are  filled  with  water,  and  to  that  compartment  which  appears 
white  a  certain  measured  quantity  of  blood  is  added  and  thoroughly  mixed  with  the  water.  If 
the  room  is  now  darkened  and  a  candle  is  placed  in  front  of  the  apparatus  and  the  glass  prism 
moved  back  and  forth,  there  wiU  be  a  time  when  both  compartments  will  appear  to  have  the  same 
color.  A  reading  taken  from  the  scale  on  the  back  of  the  stage,  when  both  compartments  are  aUke, 
expresses  the  percentage  of  hEemoglobin. 

The  blood  is  measured  by  means  of  small  capillary  pipettes  fixed  in  metal  handles.  These 
are  so  small  that  if  they  are  thoroughly  clean  they  will  immediately  become  filled  by  capillary 
attraction  if  one  end  is  touched  to  a  drop  of  blood,  obtained  in  the  usual  way.     Three  or  four  of 

785 


786  THE   BLOOD 

The  red  corpuscles  are  normallj'  about  5,000,000  to  the  cubic  millimetre).  They 
are  circular  biconcave  disks,  homogeneous  in  structure,  and  devoid  of  nuclei.  Their 
average  diameter  is  tjVo  of  an  inch  (seven  to  nine  micro-millimetres).  By  trans- 
mitted light  they  have  a  faint  amber  color  and  are  fairly  transparent.  The  margins 
are  smooth  in  general,  but  they  sometimes  appear  with  broken  or  serrated  edges, 
due  to  contact  with  the  air.  This  condition,  Icnown  as  crenation,  differs  from 
poikilocytosis,  a  distortion  of  the  cells  due  to  a  diseased  condition  to  be  considered 
later. 

At  times  when  the  red  cells  are  numerically  near  the  normal  (5  mm.  to  the 
cubic  millimetre)  they  still  show  certain  characteristic  deformities  of  the  individual 
cells  (poikiloc3'tosis),  as  well  as  variations  in  size  in  the  presence  of  microcytes  and 
macrocytes  which  appear  in  the  field  and  are  not  seen  in  the  normal  blood.  Eed 
corpuscles  which  are  paler  than  normal,  and  which  readily  undergo  crenation  and 
do  not  form  rouleaux,  are  evidences  of  anaemia. .  The  danger  signals  are  still  further 
in  evidence  when  nucleated  red  cells  (erythroblasts)  appear,  and  to  these  are  added 
the  giant  red  cells  (megaiocytes)  or  the  abnormally  small  microcytes,  the  conditions 
are  still  more  serious,  since  these  corpuscles  never  exist  in  the  normal  blood. 

The  leucocytes  vary  in  number  from  4,000  to  10,000  to  the  cubic  millimetre, 
the  average  being  about  7,000,  and  in  size  from  10  to  25  /x  or  more.  They  may  be 
divided  for  clinical  study  into  five  jDrincipal  types — the  poljiiuclear  neutrophiles, 
lymphocytes,  eosinophiles,  transitionals,  and  myelocytes.  The  polj'nuclear  neutro- 
philes vary  in  size  from  6  to  15  /x.  They  consist  of  a  nucleus  and  protoplasm, 
which  latter  is  thickly  studded  with  fine,  irregular  granulations  and  is  readily 
stained  with  neiitral  dyes.  The  nucleus  is  partly  or  wholly  divided  into  fragments, 
usually  three  in  number.  In  a  combination  of  eosin  and  methylene  blue  the 
nucleus  is  stained  blue  and  the  protoplasm  pink,  with  red  granulations.  In  the 
normal  blood  from  sixty  to  eighty  per  cent  of  the  white  cells  is  of  the  polynuclear 
variety,  while  in  disease'  they  may  constitute  as  low  as  five  per  cent  or  as  high 
as  ninety-five  per  cent. 

The  lymphocytes  measure  from  9  to  15  )«,  in  diameter.  They  have  a  single 
nu.cleus,  and  with  the  eosin  and  methylene  blue  combination  stain  both  nucleus 
and  protoplasm  are  colored  blue.  They  are  divided  into  large  and  small  types. 
The  protoplasm  is  rarely  observed  as  granular.  The  nucleus  is  either  round  or 
oval,  and  stains  much  more  markedly  than  the  protoplasm.  This  type  of  cell  con- 
stitutes from  twenty  to  forty  per  cent  of  the  white  count,  but  in  disease  it  may 
also  vary  from  less  than  five  to  more  than  ninety-five  per  cent. 

The  eosinophile  leucocytes  greatly  resemble  the  pol3Tiuclear  neutrophiles,  but 
their  protoi^lasm  is  studded  with  large,  distinct,  well-marked  spherical  granules, 
which  are  highly  refractive  and  which  are  deeply  stained  with  eosin.  Ordinarily 
but  two  fragments  to  the  nucleus  are  observed.  They  constitute  from  one  to  four 
I^er  cent  of  the  white  count,  but  in  lesions  may  reach  forty  per  cent. 

The  transitional  leu.coc.ytes  are  about  the  size  of  the  polynuclear,  but  are  mono- 
nucleated  with  their  nuclei  in  some  modification  of  a  horseslioe  in  shape.  The 
nuclei  and  protop)lasm  are  stained  blue  with  the  eosin  and  methylene  blue  combina- 
tion.   There  are  no  granules  in  the  protoplasm. 

The  relative  number  of  leucocytes  in  any  quantity  of  blood  and  their  proportion, 
to  the  red  corpuscles  can  be  readily  determined  by  the  use  of  the  Thoma-Zeiss 
apparatus,  which  consists  of  two  pipettes,  one  for  the  red  and  one  for  the  white  cells, 
with  a  well-outlined  slide  or  counting  apparatus.  It  is  employed  with  the  ordinary 
one-sixth  laboratory  objective.  It  may  be  well  to  state  that  at  the  sea  level  the 
average  number  of  red  cells  per  cm.  is  5,000,000  in  men  and  4,500,000  in  women, 

these  are  furnished  with  each  instrument,  and  it  is  well  to  know  that  the  number  stamped  on  their 
metal  handles  must  correspond  with  that  stamped  on  the  pillar  of  the  stand.  They  must  be 
kept  scrupulously  clean,  as,  when  otherwise,  they  cannot  be  filled. 

When  measuring  the  blood  the  pipette  should  be  evenly  filled  and  none  should  adhere  to  its 
end  or  outer  surface.  As  soon  as  filled,  it  should  be  placed  in  the  half-filled  cell  of  the  apparatus, 
and  with  the  accompanying  glass  pipette  washed  clean  of  all  trace  of  blood.  Both  compartments 
must  be  filled  even  with  the  top,  taking  care  that  the  fluid  of  one  side  does  not  mix  with  that  of 
the  other.  The  practiced  eye  will  without  difficulty  recognize  the  blending  of  the  colors  and  may 
then  read  off  the  haemoglobin  percentage  on  the  apparatus. 


THE   BLOOD  787 

and  6,000.000  in  the  young  and  more  rigorous  adults,  ■wMle  the  "white  cells  average 
about  T.oOO  per  cm.  for  each  ses.  The  proportion  of  red  cells  is,  in  general, 
increased  vrith  the  altitude. 

To  obtaia  blood  for  examination,  cleanse  the  lobe  of  the  ear  or  the  tip  of  the 
finger,  and  with  a  clean  small  lance  make  a  puncture  just  deep  enough  to  cause 
the  blood  to  flow  without  forcing  it  out  by  pressure.  Have  three  or  four  perfectly 
clean  slides  and  cover-slips  in  readiness,  and  when  the  first  drop  appears  wipe  it 
away  with  gauze  and  quickly  touch  the  tip  of  the  new  drop  with  the  slide  and 
immediately  cover  the  blood  with  a  cover-slip.  Secure  three  or  four  such  specimens, 
and  one  of  them  is  likely-  to  be  so  thia  that  the  corpuscles  will  not  overlay  each 
other.  If  the  slide  has  not  been  too  cold  this  preparation  will  kit  for  half  an 
hour,  and  may  be  examined  during  that  time  with  a  jij-  oil  immersion  objective. 

To  prepare  a  stained  specimen  the  blood  must  be  thinly  and  evenly  spread  over 
the  surface  of  the  glass.  To  do  this  the  drop  of  blood  is  placed  on  the  slide  near 
one  end,  and  as  quickly  as  possible  the  end  of  another  slide  is  lightly  drawn  over 
the  drop  along  the  slide.  Practice  will  enable  one  to  prepare  a  thin,  even,  and 
broad  smear  in  which  the  corpuscles  will  be  evenly  distributed  and  not  overlay. 
The  more  Cjuickly  the  smear  is  dried,  the  less  erenation  will  occur  and  the  better 
will  be  the  result.  A  nitmber  may  be  prepared  at  the  bedside  for  examination  at 
leisure.    If  kept  free  from  dust,  they  may  be  preserved  for  study  for  several  days. 

For  staining  purposes  two  separate  solutions  are  kept  on  hand:  Griiblers  eosin, 
one  half  gram,  pure  methyl  alcohol,  one  hundred  cubic  centimetres,  and  a  saturated 
aqueous  solution  of  methylene  blue.  Pour  a  small  quantity  of  the  eosin  solution 
over  the  dried  smear,  add  a  little  water,  and  then  wash  off  with  water.  It  is  now 
covered  with  the  methylene  blue  solution  and  allowed  to  stand  for  a  minute  or  so, 
washed  with  water,  and  dried  thoroughly,  when  it  is  ready  for  examination. 

In  the  study  of  the  stained  specimen  of  blood  the  following  points  are  to  be 
considered:  The  size,  uniformity,  shape,  and  color  of  the  erythrocytes  (haemo- 
globin), the  presence  or  absence  of  erythroblasts  or  of  malarial  parasites ;  also  the 
number  and  varieties  of  leucocytes,  and  their  relative  proportions. 

Leucocytes. — An  increase  in  the  number  of  white  corpuscles  occurs  under  certain 
conditions  which  are  practically  normal.  Leucocytosis  is  present  during  digestion 
from  two  to  four  hours  after  eating;  it  follows  severe  and  prolonged  muscular 
exercise,  may  even  be  temporarily  observed  in  the  reaction  from  a  cold  bath,  and 
is  always  coincident  with  the  late  months  of  pregnancy.  While  under  these  condi- 
tions the  number  of  leucocytes  is  increased,  there  remains  the  normal  proportion 
of  the  various  cell  elements  to  each  other,  the  whole  count  rarely  going  bevond 
10,000. 

In  a  pathological  leucocytosis,  while  there  is  almost  always  an  increase  in  the 
number  of  white  cells,  this  is  not  absolutely  essential,  the  true  condition  of  leuco- 
cytosis being  an  increased  percentage  of  one  or  another  type  of  cell,  usually  the 
polynuclear  neutrophile.  There  are  also  conditions  in  which  the  eosinophiles  are 
proportionately  increased,  while  in  others  tliis  holds  true  of  the  lymphocytes. 

Leucocytosis  occurs  in  aU  infectious  fevers  except  malaria,  measles,  mumps, 
tuberculosis,  influenza,  and  typhoid  fever,  in  aU  of  which  there  is  more  likely  to 
be  a  diminution  (leucopenia).  Leucocytosis  is  the  rule  in  hfemorrhage,  diarrhcea, 
vomiting,  and  acute  abscess,  and  it  foUows  the  administration  of  certain  drugs, 
such  as  potassitim  chlorate,  phenacetine.  arsenic,  oil  of  turpentine,  antipyrine, 
antifebrin,  chloroform,  ether,  quinine,  salicylates,  and  tuberculin. 

In  the  differential  diagnosis  between  a  neoplasm  of  the  breast  and  an  abscess  the 
increased  leucocvte  count  would  indicate  the  septic  process. 

An  hour  and  for  several  hours  after  hsemorrhage  the  white  cells  are  increased 
in  number.  Cabot  gives  an  instance  of  hemorrhage  of  the  brain  which  was  diag- 
nosed by  the  presence  of  leucocytosis  otherwise  unaccounted  for.  As  between  con- 
cussion and  cerebral  hfemorrhage,  the  leucocyte  count  is  in  favor  of  the  latter. 

In  general  a  white  blood  count  above  10,000  may  be  considered  as  a  leucocytosis. 
In  an  acute  infective  process  (as  in  appendicitis)  it  will  rise  in  proportion  to  the 
resistance  of  the  tissues.  This  rise  does  not  add  to  the  gravity  of  the  prognosis, 
but  it  does  indicate  an  increasing  infection. 


788  THE   BLOOD 

In  the  present  condition  of  our  knowledge  the  following  conclusions  may  be 
accepted : 

A  slight  polynuclear  increase  with  a  pronounced  leucocyte  increase  indicates 
slight  infection  and  good  resistance. 

When  the  poljaiuclear  and  leucocyte  increase  are  both  pronounced,  there  is 
severe  infection  and  good  resistance. 

A  pronounced  polynuclear  increase,  with  little  or  no  leucocyte  increase,  indi- 
cates severe  infection  and  good  resistance. 

When  the  polynuclear  jjercentage  is  increased  with  a  decrease  in  the  number 
of  leucocytes,  the  indications  are  increasing  infection  and  decreasing  body  re- 
sistance. 

A  decreasing  polynuclear  count  and  a  diminishing  leucocyte  count  indicates 
improvement. 

Using  the  leucocyte  count  as  an  aid  in  diagnosis,  all  physiological  leucocytoses 
must  be  carefully  excluded.  In  the  differentiation  Ijetween  incipient  appendicitis 
and  a  develojjing  tyj)hoid,  a  leucocytosis  would  point  strongly  to  appendicitis. 
The  count  is  here  of  great  value  for  the  reason  that  it  can  be  made  before  Widal's 
reaction  is  present. 

When  the  resistance  is  approximately  normal,  all  acute  septic  infections  are 
accompanied  by  a  more  or  less  well-pronounced  increase  in  the  number  of  leu- 
cocytes. 

A  lowering  of  the  leucocyte  count,  with  improvement  in  the  general  symptoms, 
justifies  a  favorable  prognosis,  wiile  a  smaller  count  with  increased  general  symp- 
toms is  unfavorable. 

"  When  a  spreading  peritonitis  is  diagnosed  from  the  clinical  evidence,  the 
leucocyte  count  is  of  great  value  as  an  indication  of  the  patient's  resistance.  Oper- 
ation upon  a  patient  with  a  swollen  tympanitic  abdomen,  high  fever,  rapid  pulse, 
and  a  low  leucocyte  count-  is  but  to  court  disaster."     ( Deaver. ) 

In  the  differentiation  of  ulcer  of  the  stomach  from  carcinoma  of  this  organ, 
there  is  more  apt  to  be  a  marked  anaemia  with  the  latter  than  the  former.  In 
pelvic  infection,  puerperal  sepsis,  salpingitis,  ruptured  tubal  pregnancy,  and 
monorrhagia,  leucocytosis  is  the  rule.  It  is  not  the  rule  in  the  gonorrhoeal 
infections. 

While  under  some  septic  conditions  there  may  be  slight  or  no  increase  of 
leucocytes,  there  may  be  noticed  a  diminution  of  the  red  corpuscles,  accompanied 
by  a  corresponding  fall  in  the  hffimoglobin  percentage.  A  red  cell  count  below 
3,500,000,  with  diminished  haemoglobin,  may  be  considered  as  of  decidedly  un- 
favorable import. 

Meningitis  is  accompanied  by  leucocytosis  even  when  of  tubercular  origin,  and 
this  is  claimed  to  be  the  only  tubercular  lesion  accompanied  by  an  increase  of 
the  white  cells. 

Pleural,  pericardial,  and  peritoneal  infections  are  accompanied  by  leucocytosis. 

The  white  cells  are  rapidly  increased  in  intestinal  obstruction,  there  being  a 
comparatively  higher  count  with  total  than  with  partial  occlusion.  When  gangrene 
ensues,  the  leucocyte  count  falls. 

In  differentiation  between  cancer  of  the  stomach  and  pernicious  anaemia,  the 
following  points  are  advised  to  be  taken  into  consideration  by  Professor  Jeffries : 

In  cancer,  the  color  index  is  low;  in  pernicious  anemia,  high.  The  number 
of  white  cells  is  increased  in  the  former,  diminished  in  the  latter,  and  the  same  is 
true  of  the  lymphocytes.  The  red  cells  are  diminished  in  size  in  cancer  and  in- 
creased in  pernicious  anaemia,  and  there  will  be  found  in  the  former  normoblasts, 
•with  megaloblasts  in  the  latter.  While  the  red  cells  may  vary  in  shape  in  cancer, 
in  pernicious  antemia  there  is  a  general  tendency  to  assume  an  oval  form. 

Wlienever  a  leucocytosis  accompanies  a  tumor,  it  suggests  the  malignant  nature 
of  the  neoplasm. 

Ancemia. — The  fact  that  pallor  does  not  always  indicate  anaemia  emphasizes 
the  necessity  for  a  careful  study  of  the  blood  to  detect  its  exact  condition. 

Secondary  ancemia,  a  condition  which  occurs  with  and  follows  protracted  fevers, 
practically  all  forms  of  infection  or  neoplasms  which  interfere  in  any  way  with 


THE   BLOOD  789 

nutrition  (cancer  of  the  stomach),  ha?niorrhage,  parasitic  diseases,  starvation,  bad 
hygiene,  and  the  prolonged  action  of  certain  chemical  fioisons,  is  of  especial  interest 
to  the  surgeon.  The  blood  is  paler  in  color  than  normal,  the  red  disks  will  be 
found  to  vary  in  size  and  shape  -  with  an  average  increase  in  diameter,  whUe 
the  hgemoglobin  will  range  from  fifty  to  seventy  per  cent.  The  red  cells  average 
from  3,000,000  to  4,000,000  to  the  cm.,  and  as  a  rule  there  will  exist  a 
leucoej'tosis. 

Chlorosis. — In  chlorosis,  which  occurs  usualh"  in  young  girls  about  puberty  and 
from  which  voung  men  are  not  entirelv  exempt,  the  average  red  cell  count  varies 
from  4,000,000  to  2,000,000,  rarely  falling  so  low  as  1,000,000,  with  from  thirty 
to  fifty  per  cent  of  haemoglobin.  While  the  red  cells  vary  in  shape,  size,  and 
color  as  given  for  secondary  ansemia,  there  is  in  chlorosis,  as  a  rule,  no  leucoc3i;osis, 
while  the  erythroblasts  are  more  common. 

In  pernicious  anfemia  the  average  diameter  of  red  cells  is  increased,  and  the 
count  as  given  by  Cabot  will  average  1,000,000  per  cm.  The  white  cells  are 
also  fewer,  varying  from  4,200  to  so  low  a  count  as  500,  with  lymphoej'tosis 
as  a  prominent  feature.  Megaloblasts  are  plentiful  in  pernicious  ansemia,  and 
are  rarely  met  with  in  chlorosis.  The  cause  of  pernicious  anaemia  is  as  yet  un- 
discovered. It  has  been  observed  that  it  is  usually  associated  with  a  change  in 
bone  marrow. 

In  leulcamia  there  is  a  marked  increase  of  leucocytes  with  a  largely  dispropor- 
tionate increase  of  the  mononuclear  cells.  The  lymph  glands  and  spleen  are 
enlarged,  and  there  are  marked  changes  in  the  bone  marrow.  The  two  varieties 
of  leuka?mia  are  the  hjmphaiic  and  tlie  myelogenous.  In  lympliaiic  leuka;niia  the 
erjihrocyte  count  is  diminished,  usually  to  about  3,000,000.  AH  forms  of  erythro- 
blasts are  common  and  the  haemoglobin  is  diminished.  The  average  leucocyte 
count  is  100,000,  and  about  ninety  per  cent  are  lymphocytes.  Myeloc^-tes  are 
infrecpent.  In  myelogenous  leuka?mia  the  erytliroc}i:e  count  is  about  3,000,000. 
Erythroblasts  ^  of  all  forms  are  abundant  and  tlie  haemoglobin  is  duninished.  The 
average  leucocyte  count  is  400,000 ;  lymphocytes  about  seven  per  cent ;  polynu- 
clears  about  fifty  per  cent ;  eosinophiles,  four  per  cent,  and  myelocytes  about  thirty- 
five  per  cent.  The  large  ratio  of  myelocytes  is  very  characteristic.  Myelocytes 
vary  in  size  from  15  to  25  /a.  They  are  mononucleated,  with  an  indistinct,  pale, 
oval  nucleus  which  is  generally  eccentrically  located.  The  protoplasm  is  abundant, 
and  is  possessed  of  neutrophile  granules  in  one  type  and  eosinopliile  granules  in 
another.  The  cell  is  not  found  in  the  normal  peripheral  blood,  but  is  foimd 
normally  in  bone  marrow.  It  appears  in  the  circulation  in  certain  pathologic 
conditions. 

Leul-cemia  should  be  differentiated  from  Hodgkin's  disease,  tubercular  ade- 
nitis, sarcoma,  and  malaria.  Tuberculosis  and  sarcoma  are  easily  recognized 
from  the  physical  signs,  while  malaria  may  be  determined  by  a  blood  exami- 
nation. 

In  Hodgkin's  disease  the  changes  in  the  blood  are  so  slight  when  compared  with 
those  given  for  leuksmia  that  the  differentiation  is  not  difficult. 

Bacteria. — For  bacterial  examination  the  blood  is  best  obtained  from  a  vein  in 
the  bend  of  the  elbow.  Under  careful  asepsis,  ten  to  twenty-five  cubic  centimetres 
should  be  withdrawn  with  a  sterile  aspirating  needle  or,  preferably,  glass  tube.  It 
should  at  once  be  subdivided  in  culture  tubes  for  various  dilutions,  and  these  are 
placed  in  the  incubator  for  development  and  identification. 

The  following  organisms  may  be  recognized :  Typhoid  and  paratj-phoid  bacillus, 
colon  bacillus,  staphylococcus,  streptococcus,  gonococcus,  pneimiococcus,  meningo- 
coccus, anthrax,  glanders,  and  bubonic  plague. 

The  tubercle  bacillus  has  been  repeatedly  found  in  the  blood,  but  is  more 
readily  found  twentj^-four  hours  after  the  administration  of  tuberculin. 

■  Concerning  blood  platelets,  the  third  variety  of  corpuscle,  little  is  known  and  at  present  they 
are  of  no  aid  in  diagnosis.  They  are  small  bodies  about  half  the  diameter  of  errthrocjtes.  possess 
an  indistinct  nucleus  and  a  homogeneous  protoplasm.  They  mmiber  from  200.000  to  400,000 
to  the  centimetre  and  have  a  marked  tendency  to  gather  in  clumps.  They  may  be  mistaken  for 
malarial  parasites. 


790  THE   BLOOD 

The  spirochete  pallida  may  be  demonstrated  in  the  blood  and  serum  at  all 
stages  of  syphilitic  infection,  but  is  more  readily  found  in  mucous  patches  and 
at  the  edges  of  the  initial  lesion.  To  obtain  the  material  the  surface  should  be 
scarified  till  the  blood  flows,  and  smears  are  prepared  as  already  directed.  The 
dried  smear  is  then  stained  with  Goldhorn's  spirochete  stain  for  a  few  seconds, 
then  dipped  in  clean  water  with  the  smear  downward,  and  finally  washed  and 
dried.    The  parasite  may  then  be  detected  by  aid  of  a  -^-inch  objective. 


APPEITDIX 


A  COMPAEISON  of  the  standards  of  Weights  and  Measures,  taken  by  permission 
from  Borland's  American  Illustrated  Medical  Dictionar}^^ 


TABLE  OF   WEIGHTS  AND   MEASURES 


Troy  grains. 
gr.  20 


;ruples. 

31 

3 

24 

288 


APOTHECARIES'  WEIGHT 
Drams.  Troy 


51 

12 


1.295 

3.885 

31.08 

372,96 


Troy  grains, 
gr.  27.34375 
437.5 
7000 


AVOIRDUPOIS  WEIGHT 

ns.  Ounces. 


dr.  1 

16 

256 


oz.  1 
10 


Metric  equivalents. 
Grams. 
1 . 7705 

28 . 328 
453.25 


24 

480 

5760 


TROY   WEIGHT 


Pennyweights, 
dwt.  1 
20 
240 


oz.  1 
12 


Minims. 

ni^eo 

480 

7680 

61440 


APOTHECARIES'    (WINE)   MEASURE 

FluidTams.  Fluidounces.  Pints. 

f5i 


128 
1024 


f§l 

16' 
128 


Ol 


C.  1 


RELATION   OF  MEASURES  OF   U.  S.  PHARMACOPEIA  TO  CUBIC   MEASURE 


1  gallon 
1  pint 

1  fluidounce 
1  fluidram 
1  minim 


231.0  cubic  inches. 

28 .  875       cubic  inches. 

1 .  80468  cubic  inches. 

0.22558  cubic  inch. 

0.00375  cubic  inch. 


480 

9600 

76800 


IMPERIAL   MEASURE 

Fluidrams.  Fluidounces. 

1 

8  =  1 

20 
160 


160 
1280 


'  W.  B.  Saunders  and  Company,  Philadelphia,  Pa. 
791 


792 


APPENDIX 


TABLE   FOR  CONVERTING   APOTHECARIES'   INTO   IMPERIAL   MEASURE 
APOTHECARIES'  MEASURE. 


IMPERIAL  MEASURE. 
FluidouDces.     Fluidrams. 


1  minim 

1  fluidram 

1  fluidounce 

1  pint 

1  gallon 


Minims. 
1.04 
2.5 
20 
18 
23 


TABLE   FOR  CONVERTING   IMPERIAL   INTO   APOTHECARIES'   MEASURE 
IMPERIAL  MEASURE. 


APOTHECARIES'  MEASURE. 
Pint.        Fluidounces.     Fluidrams. 


1  minim 
1  fluidram 
1  fluidounce 
1  pint 
1  gallon 


Minims. 
0.96 
58 
41 
38 


RELATION    OF    WEIGHTS    AND    MEASURES    OF    U.    S.    PHARMACOPEIA 


1  pound 
1  ounce 
1  dram 
1  scruple 
1  grain 

1  gallon 
1  pint 

1  fluidounce 
1  fluidram 
1  minim 


0.7900031  pint 
1.0533376  fluidounces 
1.0533376  fluidrams 


10.1265427  pounds 
1.2658178  pounds 
0.9493633  ounce 
0.9493633  dram 


6067.2238 

505.6019 

63.2002 

21.0667 

1.0533 

58328.8862 

7291.1107 

455.6944 

56.9618 

0.9493 


APPROXIMATE   VALUE   OF   DOMESTIC   MEASURES 


Tea-cup 
Wine-glass 


fgiv. 
foij- 


Tablespoon 
Teaspoon 


fgss. 
foj. 


LINEAR  MEASURE 


Lines. 
1 


Inches. 

0.833 

12 

36 

72 

198 

7920 

63360 


Feet. 

0.00696 

1 

3 

6 

16.5 
660 
5280 


5.5 

220 
1760 


1 

2.75 
110 


1 
40 

320 


Square  inches. 

144 

1296 

39204 

1568160 

6272640 


Square  feet. 

1 

9 

272.25 

10890 

43560 


SQUARE   MEASURE 

Square  yards.  Square  perches. 


1 
30.25 

1210 
4840 


1 
40 

160 


Cubic  inches. 

1728 

46656 


SOLID   MEASURE 

Cubic  feet. 

1 

27 


Cubic  yard. 
1 


16 

64 

512 


Quarts. 

1 

4 

8 

32 

256 


DRY   MEASURE 

Gallons.  Pecks. 


Bushels.  Quarter. 


APPENDIX 


793 


METRIC  WEIGHTS   AND   MEASURES 


The  meter,  or  unit  of  length,  at  32°  F., 
The  liter,  or  unit  of  capacity, 
The  gram,  or  unit  of  weight. 


39 .  370432  inches. 
33.816  fiuidounces. 
15.43234874  troy  grains. 


METRIC   MEASURES   OF   LENGTH 

1  myriameter  =   10000  meters. 

1  kilometer  =     1000  meters. 

1  hectometer  =        100  meters. 

1  decameter  =  10  meters. 

1  meter  -  ten-millionth  part  of  a  quarter  of  a  meridian  of  the  earth. 

1  decimeter  -  tenth  part  of  1  meter,  or  0.1  meter. 

1  centimeter  =  hundredth  part  of  1  meter,  or  0 .  01  meter.. 

1  millimeter  -=   thousandth  part  of  1  meter,  or  0 .  001  meter. 


Millimeter  (mm.) 
Centimeter  (cm.) 
Decimeter  (dm.) 
Meter  (m.) 
Decameter  (Dm.) 
Hectometer  (Hm.) 
Kilometer  (Km.) 
Myriameter  (Mm.) 


English  inches. 

.03937 

.39370 

3.93704 

39.37043 

393.70432 

3937.04.320 

39370.43200 

393704.32000 


Rods. 

Yards. 

Feet. 

Inches. 

1 

0 

3.370 

10 

2 

9.704 

109 

1 

1 .  043 

160 

213 

1 

10.4.32 

40 

156 

0 

8.320 

METRIC   MEASURES   OF   CAPACITY 

1  myrialiter  =      10  cubic  meters,  or  the  measure  of  10  milliliters  of  water. 

1  kiloliter  =        1  cubic  meter,  or  the  measure  of  1  milliliter  of  water. 

1  hectoliter  =  100  cubic  decimeters,  or  the  measure  of  one  quintal  of  water. 

1  decaliter  =      10  cubic  decimeters,  or  the  measure  of  1  myriagram  of  water. 

1  liter  =       1  cubic  decimeter,  or  the  measure  of  1  kilogram  of  water. 

1  deciliter  =  100  cubic  centimeters,  or  the  measure  of  1  hectogram  of  water. 

1  centiliter  =      10  cubic  centimeters,  or  the  measure  of  1  decagram  of  water. 

1  milliliter  =        1  cubic  centimeter,  or  the  measure  of  1  gram  of  water. 


English  Cubic  Inches.        Apothecaries'  Measure. 


Milliliter  (c.c.) 
Centiliter  (cl.) 
Deciliter  (dl.) 
Liter  (1.) 
Decaliter  (DI.) 
Hectoliter  (HI.) 
ICiloUter  (Ivl.) 
Myriahter  (Ml.) 


.061028 

.610280 

6.102800 

61.028000 

610.280000 

-   6102.800000 

=  61028.000000 

=  610280.000000 


16.2318  minims. 

2 .  7053  fluidrams. 

3 .  3816  fluidounces.    Tons. 
2. 1135  pints. 

2.6419  gallons. 

1 
10 


English. 


26.419 

12.19 

58.9 


Pints. 

2.1133 
5.1352 


1  myriagram 
1  kilogram 
1  hectogram 
1  decagram 
1  gram 
1  decigram 
1  centigram 
1  milligram 


Milligram  (mg.) 
Centigram  (eg.) 
Decigram  (dg.) 
Gram  (Gm.) 
Decagram  (Dg.) 
Hectogram  (Hg.) 
Kilogram  (Kg.) 
Myriagram  (Mg.) 


METRIC   WEIGHTS 

10000  grams. 
1000  grams. 
100  grams. 
10  grams, 
weight  of  1  cubic  centimeter  of  water, 
tenth  part  of  1  gram,  or  0 . 1  gram, 
hundredth  part  of  1  gram,  or  0.01  gram, 
thousandth  part  of  1  gram,  or  0 .  001  gram. 


Troy  grains. 

.0154 

.1543 

1.5432 

15.4323 

154.32.34 

1543.2348 

154.32.. 3487 

154323.4874 


tb  (troy).  5 

3 

2  8 

26  9 


Gr. 

34.3 

43.2 

12.3 

3.4 


794 


APPENDIX 


VALUE   OF   AVOIRDUPOIS   WEIGHTS   AND    IMPERIAL   MEASURES   IN    METRIC 
WEIGHTS   AND   MEASURES 


Avoirdupois  Weiglits. 

Metric  Weights. 

Imperial  Measures. 

Metric  Measures. 

1  pound 

453.5925  grams. 

1  gallon 

= 

4.543487  liters 

1   ounce 

28.3495  grams. 

1  pint 

= 

0.567936  liter. 

1  grain 

0.0648  gram. 

1  fluidounce 

= 

0.028396  liter. 

1  fluidram 

= 

0.003549  liter. 

1  minim 

= 

0.000059  liter. 

COMPARATIVE   VALUES   OF   STANDARD   AND   METRIC    MEASURES    OF    LENGTH 


Inches. 

Centimeters. 

Inches. 

Centimeters. 

Inches. 

Millimeters. 

Inches. 

Millimeters. 

12 

=.       30.48 

6 

15.24 

^ 

1.00 

s 

15.85 

11 

=       27.94 

5 

=       12.70 

tV 

2.11 

f 

16.92 

10 

=       25.40 

4 

10.16 

i 

3,17 

f 

19.05 

9 

=       22.86 

3 

7.62 

i 

6.35 

t 

21.15 

8 

=       20.32 

2 

5.08 

8.46 

I 

22.19 

7 

=       17.78 

1 

2.54 

' 

12 .  70 

H       - 

23.28 

COMPARATIVE    VALUES    OF  APOTHECARIES'    AND    METRIC    FLUID    MEASURES 


Minims. 

Cubic 

Minims. 

Cubic 

Fluid- 

Cubic 

Fluid- 

Cubic 

Centimeters. 

Centimeters. 

Centimeters. 

ounces. 

Centimeters. 

1 

0.03 

25  '       = 

1.54 

1 

30.00' 

21 

=       621.00 

2 

0.12 

30 

1  90 

2 

59.20 

22 

-       650.00 

3 

0.18 

35 

2.16 

3 

89.00 

23 

=       680.00 

4 

0.24 

40 

2.50 

4 

=       118.40 

24 

=       710.00 

5 

0.30 

45 

2.80 

5 

148.00 

25 

=       740.00 

6 

0.36 

50 

3.08 

6 

178.00 

26 

-       769.00 

7 

0.42 

55 

3.40 

7 

=       207.00 

27 

798 . SO 

8 

0.50 

Fiuidrams. 

8 

=       236.00 

28 

=       828.00 

9 

0.55 

1 

3.75 

9 

=       266.00 

29 

=       858.00 

10 

0.60 

H      = 

4.65 

10 

=       295.70 

30 

=       887.25 

11 

0.68 

1*     = 

5.60 

11 

=       325.25 

31 

=       917.00 

12 

0.74 

ll     = 

6.51 

12 

=       355.00 

32 

=       946.00 

13 

0.80 

2           = 

7.50 

13 

=       385.00 

48 

=     1419.00 

14 

0.85 

3 

11.25 

14 

=       414.00 

56 

=     1655.00 

15 

0.92 

4 

15.00 

15 

444 . 00 

64 

=     1892.00 

16 

1.00 

5 

18.50 

16 

=       473.11 

72 

=     2128.00 

17 

1.05 

6 

22.50 

17 

=       503.00 

80 

=     2365.00 

18 

1.12 

7 

26.00 

18 

=       532.00 

96 

=     2839.00 

19 

1.17 

19 

=       562.00 

112 

=     3312.00 

20 

1.25 

20 

=       591.50 

128 

=      3785.00 

COMPARATIVE  VALUES  OF  METRIC  FLUID  AND  APOTHECARIES'  MEASURES 


Cubic 

Fluid- 

Cubic 

Fluid- 

Cubic 

Fiuidrams. 

Cubic 

Minims. 

Centimeters. 

ounces. 

Centimeters. 

Centimeters. 

Centimeters. 

1000       = 

33.81 

400 

13.53 

25 

6.76 

4 

64.8 

900       = 

30.43 

300 

10.14 

10 

2.71 

3 

48.6 

800      = 

27.05 

200 

6.76 

9 

2.43 

2            = 

32.4 

700      = 

23.67 

100 

3.38 

8 

2.16 

1 

16. 00= 

600      = 

20.29 

75 

2.53 

7 

1.89 

0.09      - 

1.46 

500      - 

16.90 

50 

1.69 

6 

1.62 

0.07      = 

1.14 

473      = 

16.00 

30 

1.00' 

5 

1.35 

0.05      = 

0.81 

^  More  accurately,  1.01. 


^More  accurately,  16.23. 


APPENDIX 


795 


COMPARATIVE   VALUES  OF   METRIC   AJv^D   APOTHECARIES'  WEIGHTS 


Grams. 

Grains. 

Grams. 

Grains. 

Grams. 

Grains. 

Grams. 

Grains. 

0.0010 

=          A- 

0.065 

=     1.003 

1 

15.43 

100     = 

=      1543.23 

0.0020 

=           3-V 

0.100 

=     1.543 

2 

30.86 

125     = 

=      1929.04 

0.0040 

=           h 

0.130 

=     2.006 

3 

46.30 

150     = 

=-      2314.85 

0.0065 

=           iV 

0.150 

=     2.315 

4 

61.73 

175     - 

=      2700.65 

0.0081 

—            1 

0.180 

=     2.778 

5 

77.16 

450     = 

=      6944.55 

0.0108 

=            i 

0.200 

=     3.086 

6 

92.60 

550    = 

=      8487.78 

0.0162 

=            i 

0.300 

=     4.630 

7 

108.01 

650     = 

=    10031.01 

0.0324 

i 

0.500 

=^     7.716 

8 

123.46 

750     = 

=    11574.26 

0.0486 

=            f 

0.700 

-   10.803 

9 

138.90 

850     = 

=    13117.49 

0.0567 

=            i 

0.900 

=   13.890 

10 

154.32 

1000     = 

=    15432.35 

COMPARATIVE   VALUES   OF   APOTHECARIES'   AND   METRIC  WEIGHTS 


Grains. 

Grams. 

Grains. 

Grams. 

Grains. 

Grams. 

Drams. 

Grams. 

riv 

=      0.00065 

1 

0.065 

24 

1.55 

1 

3.90 

^       = 

=      0.00101 

2 

0.130 

25 

1.62 

2 

7.80 

■    ^       = 

=      0.00108 

3 

0.195 

26 

1.70 

3 

11.65 

aV        = 

=      0.00130 

4 

0.260 

27 

1.75 

4 

15.50 

4^-            = 

=      0.00135 

5 

0.324 

28 

1.82 

5 

19.40 

4V             = 

=      0.00162 

6 

0.400 

29 

1.87 

6 

23.30 

^             ' 

=      0.00180 

7 

0.460 

30 

1.95 

7 

27.20 

^^             ' 

=      0.00202 

8 

0.520 

31 

2.00 

Ounces. 

bV         = 

=      0.00216 

9 

0.600 

32 

■2.10 

1 

31  10= 

iV      = 

=      0.00259 

10 

0.650 

33 

2.16 

2 

62.20 

iri      ' 

=      0.00270 

11 

0.715 

34 

2.20 

3 

93.30 

A-      = 

=      0.00324 

12 

0.780 

35 

2.25 

4 

=       124.40 

=      0.00360 

13 

0.845 

36 

2.30 

0 

155.50 

-iV      - 

■      0.00405 

14 

0.907 

37 

2.40 

6 

=       186.60 

-iV      = 

"      0.00432 

15         = 

0.972 

38 

2.47 

7 

=       217.70 

1^      = 

=      0.. 00540 

15.5'    = 

1.000 

39 

2.55 

8 

=       248.80 

A      = 

=      0.00648 

16 

1.040 

40 

2.60 

9 

=       280,00 

i       = 

=     '0.00810 

17 

1.102 

42 

2.73 

10 

=       311.00 

=      0.01080 

18 

1.160 

44 

2.86 

11 

=       342.14 

^ 

=      0.01296 

19 

1.240 

48 

3.00 

12 

=       373.23 

i       - 

=      0.01620 

20 

1.300 

50 

3.25 

14 

=       435.50 

=      0.2160 

21 

1.360 

52 

3.40 

16 

=       497.60 

^ 

=      0.03240 

22         = 

1.425 

56     •    - 

3.65 

24 

=       746.40 

a. 

=      0.04860 

23 

1.460 

58 

•3.75 

48 
100 

=     1492.80 
=     3110.40 

COMPARATIVE   VALUES   OF   AVOIRDUPOIS  AND   METRIC   WEIGHTS 


Avoir. 
Ounces. 

Grams. 

Avoir. 
Ounces. 

Grams. 

Avoir. 
Ounces. 

Grams. 

Avoir. 
Pounds. 

Grams. 

A        = 

1.772 

5 

141.75 

13 

368.54 

3 

1.360.78 

i         = 

3.544 

6 

170.10 

14 

396.90 

4 

1814.37 

i         = 

7.088 

7 

198.45 

15 

425.25 

5 

2267.96 

^         = 

14.175 

S 

226.80 

6 

2727.55 

1 

28.350 

9       - 

255.15 

Pounds. 

7 

3175.14 

2       = 

56 . 700 

10 

283,50 

1 

453.60 

8 

3628.74 

3       = 

85 . 050 

11 

311.84 

2 

907.18 

9 

4082.33 

4       = 

113.400 

12 

•  340.22 

2.2     = 

1000.00 

10 

4535.92 

^  More  accurately.  15.432+gr.  =  1  gram. 


'  More  accurately,  31.10349  grams. 


796  APPENDIX 

COMPARATIVE   VALUES   OF   METRIC   AND   AVOIRDUPOIS  WEIGHTS 


Grams.              Oz.        Gr. 

Grams. 

Oz. 

Gr. 

Grams. 

Oz. 

Gr. 

Grams. 

Oz. 

Gr. 

28.35    = 

38      - 

1 

149 

125        = 

4 

179 

600      = 

=      21 

72 

29 

L       10 

39      = 

1 

164 

150        = 

5 

127 

650      = 

22 

405 

30 

L        25 

40      = 

1 

180 

200        = 

7 

24 

700      = 

=      24 

303 

31          =      ] 

41 

50      = 

1 

334 

250       = 

8 

358 

750      = 

-      26 

198 

32          =      ] 

56 

60      = 

2 

50 

300      = 

=      10 

255 

800      = 

=      28 

96 

33 

72 

70      = 

2 

205 

•350      - 

=      12 

152 

850      - 

29 

429 

34 

87 

80      = 

2 

360 

400       = 

=       14 

48 

900      = 

31 

326 

35          =      ] 

103 

85      - 

3 

450       = 

=      15 

382 

950      = 

33 

222 

36 

118 

90      = 

3 

76 

500      = 

=    "17 

279 

1000      = 

35 

120 

37 

133 

100      = 

3 

230 

550      = 

=      19 

175 

TABLE   OF   EQUIVALENTS   OF   CENTIGRADE   AND   FAHRENHEIT 
THERMOMETRIC   SCALES 


Cent. 

Fahr. 

Cent. 

Fahr. 

Cent. 

Fahr. 

Degrees. 

Degrees. 

Degrees. 

Degrees. 

Degrees. 

Degrees. 

-40 

-40.0 

9 

48.2 

57 

134.6 

-39 

-38.2 

10 

50.0 

58 

136.4 

-38 

-36.4 

11 

51.8 

59 

138.2 

-37 

-34.6 

12 

53.6 

60 

140.0 

-36 

-32.8 

13 

55.4 

61 

141.8 

-35 

-31.0 

14 

57.2 

62 

143.6 

-34 

-29.2 

15 

59.0 

63 

145.4 

-33 

-27.4 

16 

60.8 

64 

147.2 

-32 

-25.6 

17 

62.6 

65 

149.0 

-31 

-23.8     ■ 

18 

64.4 

66 

150.8 

-30 

-22.0 

19 

66.2 

67 

152.6 

-29 

-20.2 

20 

68.0 

68 

154.4 

-28 

-18.4 

21 

69.8 

69 

156.2 

-27 

-16.6 

22 

71.6 

70 

158  0 

-26 

-14.8 

23 

73.4 

71 

159.8 

-25 

-13.0 

24 

75.2 

72 

161.6 

-24 

-11.2 

25 

77.0 

73 

163.4 

-23 

-   9.4 

26 

78.8 

74 

165.2 

-22 

-   7.6 

27 

80.6 

75 

167.0 

-21 

-  5.8 

28 

82.4 

76 

168.8 

-20 

-   4.0 

29 

84.2 

77 

170.6 

-19 

—   2.2 

30 

86.0 

78 

172.4 

-18 

-   0^4 

31 

87.8 

79 

174.2 

-17 

+    1.4 

32 

89.6 

80 

176.0 

-16 

3.2 

33 

91.4 

81 

177.8 

-15 

5.0 

34. 

93.2 

82 

179.6 

-14 

6.8 

35 

95.0 

83 

■181.4 

-13 

8.6 

36 

96.8 

84 

183.2 

-12 

10.4 

37 

98.6 

85 

185.0 

-11 

12.2 

38 

100.4 

86 

186.8 

-10 

14.0 

39 

102.2 

87 

188.6 

-9 

15.8 

40 

104.0 

88 

190.4 

-8 

17.6 

41 

105.8 

89 

192.2 

-7 

19.4 

42 

107.6 

90 

194.0 

-6 

21.2 

43 

109.4 

91 

195.8 

-5 

23.0 

44 

111.2 

92 

197.6 

-4 

24.8 

45 

113.0 

93 

199.4 

-3 

26.6 

46 

114.8 

94 

201.2 

-2 

28.4 

47 

116.6 

95 

203.0 

-1 

30.2 

48 

118.4 

96 

204.8 

0 

32.0 

49 

120.2 

97 

206.6 

+  1 

33.8 

50 

122.0 

98 

208.4 

2 

35.6 

51 

123.8 

99 

210.2 

3 

37.4 

52 

125.6 

100 

212.0 

4 

39.2 

53 

127.4 

101 

213.8 

5 

41.0 

54 

129.2 

102 

215.6 

6 

42.8 

55 

131.0 

103 

217.4 

7 

44.6 

56 

132.8 

104 

219.2 

8 

46.4 

APPENDIX  797 

A  simple  rule  for  the  conversion  of  C'entigTade  to  Fahrenheit,  and  vice  versa: 
212°  F.  —  32  X  5  -^  9  =  100°  C. ;  100°  C.  X  9  -^  5  +  32  =  212°  F. 

Example:  212°  F. 

32 

180 
5 

9)900 
100°  C. 

Local  AnwstJtesia 

Further  experience  in  the  employment  of  endermic  and  hypodermic  injections 
of  the  hydrochloride  of  quinia  and  urea  as  a  local  anaesthetic  has  demonstrated  in 
several  instances  that  the  stronger  solution  (two  per  cent)  is  capable  of  producing 
a  necrosis  of  the  skin  along  the  lines  of  the  incision.  This  result  has  in  no  instance 
followed  the  employment  of  a  one-per-cent  solution,  and  the  local  anesthesia 
obtained  has  been  as  satisfactory  with  this  weaker  as  with  the  stronger  solution. 

In  the  present  state  of  our  "knowledge  concerning  this  newer  agent,  the  author 
is  of  the  opinion  that  the  weak  solutions  of  cocaine,  as  given  in  the  text,  will  be 
found  preferable  in  the  large  majority  of  operative  cases  where  local  anassthesia 
is  to  be  preferred,  and  that  the  quinia  and  iirea  solutions  Avill  be  valuable  in  subjects 
who  develop  an  idiosyncrasy  which  contra-indieates  cocaine.  It  is  advised  that  in 
using  the  quinia  solution,  free  infiltration  he  made  beneath  the  skin,  waiting  fifteen 
or  twenty  minutes  for  the  full  ana?sthetic  effect,  and  that  the  endermic  method  be 
either  not  employed,  or,  if  used,  the  weaker  solution  be  injected. 

The  following  formula  may  be  used  to  advantage  as  an  adjunct  to  the  local 
anesthesia  of  cocaine.  It  is  especially  recommended  by  Dr.  A.  T.  Bristow,  who  has 
employed  it  extensively,  and  so  far  without  a  symptom  to  contra-indicate  its  use, 
especially  in  the  removal  of  thyroid  enlargements : 

I^   Hyoscine  hydrobromide   y^-o'  gr. 

Atropine   . .  .  .' ^^-^    " 

Morphine  sulfihate    {-    "    ^ 

One  half  of  a  tablet  is  given  hypodermically  three  hours  before  operation.  One 
and  one  half  hours  later  this  dose  is  repeated,  and  again  just  before  the  operation  is 
begun.  The  skin  incision  is  made  after  the  usual  endermic  injection  of  a  one- 
half-of-one-per-eent  solution  of  cocaine.  Usually  the  subcutaneous  dissection  may 
be  made  without  further  infiltration,  but,  when  necessary,  the  same  cocaine  solution 
may  be  employed. 

OPERATIO^T    FOE    THE    EaDICAL    CuRE    OF    InGUIN"AL    HekNIA   IK   THE    MaLE 

Prof.  W.  S.  Halsted,  who  independently  of  Bassini's  investigations  was  one  of 
the  originators  of  the  plastic  operation  for  the  radical  cure  of  inguinal  hernia 
(generally  known  as  the  Bassini  operation),  has  since  1890  practiced  in  a  large 
number  of  operations  7ion-transplantation  of  the  spermatic  cord.  His  success  leads 
the  author  to  conclude  that  transplantation  is  not  necessary  in  inguinal  hernia3  of 
comparatively  small  size  and  of  short  duration.  When  the  hernial  opening  is  very 
large,  with  attrition  of  the  tissues  from  the  pressure  of  a  truss,  and  when  a  well- 
marked  varicocele  exists,  in  addition  to  the  jjartial  removal  of  the  enlarged  veins 
for  the  cure  of  the  varicocele,  transplantation  of  the  cord  should  be  preferred. 
When  the  internal  oblic|ue  and  transversalis  muscles,  reenforced  by  the  cremasteric 
fibers,  are  stitched  to  Poupart's  ligament,  the  cord  rests  beneath  the  line  of  sutures. 
The  procedure  is  simplified  and  the  cord  is  left  practically  in  its  normal  relation. 
This  operation  also  does  away  with  the  possible  danger  of  overcompression  of  the 

'  This  formula  is  prepared  as  a  single  tablet  by  Parke,  Davis  &  Company. 


798  APPENDIX 

cord,  which  sometimes  follows — at  least  temporarily — when  transplantation  has  been 
practiced. 

In  the  milder  cases,  where  the  opening  is  small,  and  especially  in  cases  of 
incomplete  hernias,  in  addition  to  non-transplantation,  simple  deligation  of  the 
necli  of  the  sac  at  the  peritoneal  level  will  also  suffice,  leaving  the  more  radical 
procedure  of  Macewen  in  the  treatment  of  the  sac  to  the  larger  hernias. 

Formula  for  Harrington's   {Antiseptic)   Solution 

T^   Commercial  alcohol  (ninety-four  per  cent  pure) 600  c.c. 

Strong  hvdrochloric  acid    60     " 

Water   . . ". 300     " 

Bichloride  of  mercury 8  grams. 

Many  operators  of  large  experience  prefer  this  preparation  for  cleansing  the 
hands,  which  should  first  be  put  through  the  ordinary  routine  of  washing  and 
brushing  in  hot,  clean  soap  and  water  and  then  immersing  for  two  minutes  in 
this  solution.  It  is  also  recommended  as  a  disinfectant  for  abscess  cavities  from 
which  the  drainage  is  free,  and  where  any  excess  can  be  removed  by  immediate 
irrigation  with  normal  salt  solution. 


II^DEX 


Abbe's  treatment  of  CEsophageal  strictures,  354. 

Abdomen,  wounds  of,  374;  hysterectomy,  631. 

Abdominal  injuries  in  general,  373;  aorta, 
aneurism  of,  106;  aorta,  ligation  of,  136, 
137;  section  for  intestinal  occlusion,  419; 
irrigator,  Blake's,  449. 

Abscess,  extra-dural,  293 ;  of  j  aw,  309 ;  of  antrum 
of  Highmore,  309;  chronic  alveolar,  309;  of 
palate,  317;  of  mammary  gland,  3.57;  of 
thoracic  walls,  364;  of  Brodie,  145:  of  tongue, 
325;   of   tonsil,    329;   of   neck,    331;    retro- 

Eharyngeal,  331,  647,  736;  from  foreign 
odies  in  air  passages,  344;  of  scalp,  230; 
of  frontal  sinuses,  230;  of  brain,  239;  diagnosis 
of,  243;  of  cornea,  261 ;  \Tilvo-vaginal,  603;  of 
the  vagina,  623;  of  the  liver,  hepatic,  401; 
subphrenic,  401,  402;  of  the  spleen,  411. 

Absence  of  vagina,  623. 

Absorbent  dressings,  13. 

Aconite,  in  tonsillitis,  329. 

Acquired  tumors,  of  scalp,  229. 

Acromegaly,  146. 

Acromion  process,  fracture  of,  155. 

Actinomycosis,  146,  7.53. 

Actual  cautery,  for  occlusion  of  arteries  and 
veins,  110. 

Acupuncture,  for  aneurisms,  9S. 

Acute,  osteomyelitis,  144;  periostitis,  144. 

Adenitis,  acute  infective,  85;  symptoms,  85; 
treatment,  85;  cervical,  85;  catarrhal  pharjTi- 
gitis  as  cause,  85;  tuberculous,  85;  inguinal, 
562. 

Adenoid  vegetations,  298. 

Adenoma,  of  lips,  304;  testis,  599,  712;  of 
mammary  gland,  357. 

Adhesions,  of  auricle  of  ear  to  scalp,  283; 
between  pericardimn  and  pleura,  369;  of 
stomach,  390;  of  the  clitoris,  605. 

Adrenalin,  in  haemorrhage  from  nose,  294. 

Advancement  of  insertion  of  eye  miiseles,  273. 

After-care  of  gastrectomy,  398. 

Agnew's  canalicula  knife,  257. 

Air,  entrance  in  veins  of  neck,  331. 

Air  tumor,  of  scalp,  230. 

Alcohol,  injection  for  trifacial  neuralgia,  245;  as 
cause  of  atrophy  of  optic  nerve,  281. 

Alimentary  canal,  obstruction  of,  414;  clearing 
of,  1. 

Alimentation,  colon,  349,  350. 

Allis',  inhaler,  25 ;  operation  for  congenital  dis- 
location of  hip,  656;  method  of  treating 
fractures  at  elbows,  160. 

Alveolar  abscess,  chronic,  309. 

Amaurosis,  271. 

Amblyopia,  271. 

Ametropia,  273. 

Amputation,  shoulder-joint,  59;  through  hu- 
merus, 60, 61 ;  shoulder-joint,  61,  62 ;  of  upper 
extremity,  63;  amputations,  48;  retraction  in. 


51 ;  catgut  ligatures,  51 ;  catgut  drainage,  51 ; 
sutures  in,  51;  dressing,  51;  at  knee,  73;  of 
Stephen  Smith,  70,  73,  74;  hip-joint,  75,  76, 
77,  78;  rubber  tubing  in,  77;  at  carpo-radial 
joint,  55;  at  elbow-joint,  58,  59;  tarso-meta- 
tarsal,  64;  at  tibio-tarsal  joint,  68;  medio- 
tarsal,  66;  of  Chopart,  66;  of  Esmarch,  53;  of 
middle  finger,  53:  of  Forbes,  66;  of  Pirogoff, 
66;  of  Hey,  66;  of  Lisfranc,  66;  of  Lee,  71 ;  of 
Teale,  71 ;  of  Sedillot,  71 ;  of  Malgaigne,  67;  of 
Syme,  68;  of  Wj-eth,  61,  75;  prognosis  in,  48; 
primary,  48;  secondary,  48;  special,  51;  in- 
fusion in.  49;  by  circular  skin  flaps,  50;  by 
circular  solid  flaps,  50;  by  modified  circular 
flaps,  50;  Estes'  views  on,  48;  of  Gritti,  74;  of 
the  penis,  Humphrey-,  583 ;  of  the  cervix,  626; 
of  the  finger,  692;  at  ankle-joint,  68;  time, 
48;  Esmarch's  bandage  in,  48;  transfixion 
pins,  44;  shock,  49;  nitrous  oxide,  49;  for 
malignant  neoplasms,  49;  point  of  selection, 
49;  operation,  49;  tourniquet,  50;  Trendelen- 
burg posture,  50:  flap,  50;  combination  skin 
and  muscular  flap,  50;  in  diabetics,  50;  in 
senile  gangrene,  50:  circular  flap  in,  50;  modi- 
fied circular  flap,  .50;  of  toes,  63,  64;  through 
tarsus,  66;  prognosis,  48;  classification  of,  48; 
injury  to  skin,  48;  of  hand  and  fingers,  51; 
interphalangeal,  52;  at  posterior  phalangeal 
joint,  52;  metacarpo-phalangeal  joint  of 
thumb,  53;  of  index-finger,  5.3,  54;  of  ring- 
finger,  54;  of  little  finger,  54,  55:  calcaneo- 
astragaloid  joint,  67;  at  metacarpus,  55; 
carpo-metacarpal,  55;  of  thumb,  55. 

Anaemia,  788. 

Anaesthesia,  15;  ether,  18;  chloroform,  22 
nitrous  oxide,  23;  cocaine,  25;  rectal,  28 
selection  of,  16;  in  alcoholics,  16;  in  fat  sub- 
jects, 16;  gastric  lavage,  16;  tracheotomy,  21 ; 
whiskj',  22;  artificial  respiration,  21,  22;  local, 
with  herniotomy,  465;  local,  797. 

Anastomosis,  of  the  ureter,  510;  intestinal,  420; 
end-to-end,  421 ;  lateral  intestinal,  427. 

Anatomy  of  arteries,  of  internal  carotid  artery, 
120;  of  external  carotid  artery,  121:  of 
femoral,  139;  of  the  innominate,  113;  of 
common  carotids,  114;  of  superior  thjToid, 
123;  of  lingual,  123;  of  facial  arterj',  125 _;  of 
ascending  pharj-ngeal,  126:  of  occipital 
arteries,  126;  of  posterior  auricular,  126;  of 
temporal,  126;  of  internal  maxillary,  126;  of 
subclavian,  127;  of  axillary,  132;  of  brachial, 
133:  of  intereostals,  136:  of  abdominal  aorta, 
136;  of  common  iliac,  137;  of  internal  iliac, 
138;  of  external  iliac,  138. 

Ancient  dislocation,  185. 

Anel,  deligation  in  aneurism,  96;  syringe,  258. 

Aneurism,  classification  of,  93:  spherical,  93; 
fusiform,  93,  94;  dissecting,  93,  94:  true,  93; 
false,  93,  94;  pathology  of,  93,  94;  of  arch  of 


800 


INDEX 


aorta,  93;  of  aorta,  100;  popliteal,  93,  108; 
varicose,  93,  94;  of  axillary  artery,  106;  of 
brachial  artery,  106;  of  radial  artery,  106;  of 
ulnar  artery,  106;  of  internal  mammary 
artery,  106;  of  abdominal  aorta,  106;  of 
common  iliac  artery,  107;  of  innominate 
artery,  100,  102;  of  thoracic  aorta,  99,  102;  of 
aorto-innominate,  102;  of  common  carotid, 
102;  of  vertebral  artery,  103;  of  external 
carotid,  103;  of  internal  carotid,  104;  of 
ophthalmic  artery,  104;  of  subclavian  artery, 
104;  of  ascending  aorta,  99,  100;  calcareous 
deposits  in,  94;  cirsoid  aneurism,  94;  progno- 
sis of  aneurism,  94;  gangrene  in,  94,  95; 
symptoms  of,  95;  diagnosis  of,  95;  sacculated, 
99;  treatment,  95;  by  acupuncture,  98;  by 
compression  with  fingers,  96 ;  by  flexion,  99 ; 
by  iodide  of  potassium,  95 ;  by  mercury,  95 ; 
method  of  Macewen,  98;  Wyeth's  method,  98; 
method  of  Valsalva,  95;  of  Hunter,  96;  of 
Anel,  96;  of  Brasdor,  96;  of  Wardrop,  96;  of 
Antyllus,  96;  special  aneurisms,  99;  of  de- 
scending aorta,  106;  arterio-venous,  108;  of 
gluteal  artery,  107;  of  sciatic  artery,  107;  of 
femoral  artery,  107;  of  anterior  and  posterior 
tibials,  108;  of  dorsalis  pedis,  108;  method 
of  Matas,  108;  aspiration  of,  107;  of  heart, 
369. 

Aneurismal  varix,  93,  94. 

Angeioma,  of  ear,  283;  of  scrotum,  588;  716; 
of  lips,  304;  of  tongue,  325;  venous,  88;  of 
heart,  369;  of  nipple,  356;  arterial,  87; 
capillary,  89;  Wyeth's  treatment  of,  88;  of 
lower  jaw,  312. 

Angeiotribe,  for  crushing  arteries,  111. 

Angle  of  jaw,  fracture  of,  153. 

Angular  depressions  of  nose,  298. 

Ani,  pruritus,  478-501. 

Ankle-joint,  exsection  of,  221;  diseases  of,  215; 
synovitis  of,  215;  osteo-arthritis  of,  216;  dis- 
location of,  200. 

Ankylosis,  of  inferior  maxilla,  315;  at  the  knee, 
665;  of  the  shoulder,  681. 

Anteflexion  of  the  uterus,  611. 

Anterior  tibial  artery,  ligation  of,  143;  curva- 
ture of  the  spine,  644,  645;  polar  cataract, 
267;  synechia,  263. 

Anthrax,  753,  779. 

Antisepsis,  3. 

Antiseptic  solution,  798. 

Antrum,  of  Highmore,  abscess  of,  309 ;  drainage 
of,  310;  diseases  of,  310;  tumor  of,  310;  of 
mastoid,  location  of,  291. 

Antyllus,  deligation  in  aneurism,  96. 

Anus,  absence  of,  476;  eczema  of,  478;  herpes  of, 
478;  fistula,  479;  erythema  of,  478;  pityriasis 
versicolor,  478;  atresia  of,  477;  foreign  bodies 
in,  479;  neoplasms  of,  486;  fissure,  482; 
syphilitic  chancre  of,  483,  484;  artificial,  433; 
imperforate,  438. 

Aorta,  thoracic,  aneurism  of,  99,  102 ;  aneurism 
of  abdominal,  107;  ligation  of,  for  iliac  aneur- 
ism, 107. 

Aorto-innominate  aneurism,  102. 

Appendectomy,  443. 

Appendicitis,  440. 

Arcus  senilis,  263. 

Arterial  angeioma,  87;  capillary,  89;  venous, 
88;  Wyeth's  treatment  of,  88. 

Arterioplasty,  reconstructive,  97,  98. 

Arteriorrhaphy,  operative,  98. 

Arteritis,  87;  etiology  of,  87;  sequelae  of,  87; 
thrombosis  and  embolism  in,  87;  syphilitic, 
766. 


Artery,  ligation  of  external  carotid,  121,  122;  of 
inuernal  carotid,  120;  of  superior  thyroid, 
123;  of  lingual,  123;  of  facial,  125;  of  ascend- 
ing pharyngeal,  126;  of  anterior  tibial,  143; 
ligation  of  occipital,  126;  of  internal  mam- 
mary, 131;of  posterior  tibial,  1 42 ;  of  femoral, 
139;  wounds  of,  109;  suture  of,  109;  of  pro- 
funda femoris,  141;  of  pophteal,  141,  142;  of 
intercostal,  136;  of  abdominal  aorta,  136,  137; 
of  common  iliac,  1.38;  of  internal  iliac,  138;  of 
external  iliac,  138;  of  gluteal,  138;  of  sciatic, 
138;  of  internal  pudic,  139;  of  subclavian, 
130,  131;  of  vertebral,  131;  of  axillary,  132; 
of  brachial,  133;  of  ulnar,  133,  134;  of  radial, 
133,  134;  of  innominate,  113,  114;  of  common 
carotid,  114;  inflammation  of,  87;  of  carotid 
at  root  of  neck,  118;  of  posterior  auricular, 
126;  of  temporal,  126;  of  internal  maxillary, 
126;  of  dorsalis  pedis,  143;  occlusion  of 
arteries,  110. 

Arthritis,  202;  of  ankle-joint,  215;  of  hip-joint, 
203. 

Artificial,  respiration,  Sylvester's  method,  21, 
22;  anus,  433;  limb,  time  to  apply,  71;  eye, 
time  to  wear,  265;  respiration,  in  wounds  of 
the  neck,  331. 

Ascarides,  479. 

Ascending  aorta,  aneurism  of,  99,  100;  pharyn- 
geal artery,  anatomy  of,  126;  ligation  of,  126. 

Ascites,  400;  operation  for  relief  of,  402,  403. 

Asepsis,  2,  3,  4. 

Aseptic  wounds,  healing  of,  42. 

Ashurst,  John,  remarks  on  hip-joint  amputa- 
tion, 75. 

Aspermatism,  557. 

Aspiration  of  knee-joint,  212.;  of  ankle-joint, 
215;  of  shoulder-joint,  216;  of  the  ventricles 
of  brain,  243,  244;  of  pleura,  365;  in  abscess 
of  neck,  332. 

Asthenopia,  275. 

Astigmatism,  276. 

Astragalus,  fracture  of,  181. 

Atresia  of  rectum  and  anus,  477. 

Atrophy  of  optic  nerve,  281. 

Atropine  in  iritis,  264;  in  refraction,  275. 

Auricle  of  ear,  283. 

Avulsion  of  trifacial  nerve  for  neuralgia,  247;  of 
neoplasms  in  larynx,  347. 

Axillary  artery,  aneurism  of,  106;  ligation  of, 
132. 

Bacteria,  732;  in  the  blood,  789. 

Bainbridge,  spinal  analgesia,  28. 

Balanitis,  560,  762. 

Bandage,  Velpeau's,  in  fracture  of  clavicle, 
186;  in  fracture  of  coracoid  process,  156; 
figure-of-8,  for  hand,  33;  for  shoulder  and 
upper  extremity,  .  3.3;  hip  and  abdominal 
spica,  48;  single  and  double  spica,  for  groin, 
34;  spica,  34;  Velpeau's,  for  fracture  of 
clavicle,  186;  plaster  of  Paris,  29;  simple 
spiral,  30;  of  fingers,  31;  roller,  29;  reverse 
spiral,  30,  31;  simple  figure-of-8,  30;  Es- 
march,  12;  figure-of-8,  reverse,  31;  Wyeth's 
hand,  thumb,  and  finger,  31;  of  hands  and 
fingers,  32;  of  forearm,  arm,  and  shoulder, 
32;  of  toes,  foot,  and  thigh,  33;  for  head 
and  face,  35,  36,  37;  four-tailed,  37;  four- 
tailed  cap,  38;  head  and  face  hood,  38;  skull- 
net,  for  holding  ice-bag,  38;  four-tailed, 
for  chin  and  lower  jaw,  38;  T  bandage, 
39;  Esmarch's,  29;  Martin's  rubber,  29; 
for  mammary  gland,  34,  35;  hood,  35;  for 
head   and  chin,   36;  for   fracture  of   lower 


INDEX 


801 


jaw,  36;  for  haemorrhage,  36;  knotted,  36;  for 
eye  and  upper  Kp,  37. 

Bandaging,  29;  material  for,  29. 

Bands,  constriction  by,  417. 

Banks,  E.  A.,  filiform  bougies,  568,  569. 

Barker,  exophthalmic  goitre,  336. 

Barnes'  dilator,  2. 

Bartlett,  Willard,  preparation  of  catgut,  5; 
method  of  treatment  for  wounds  of  the  ureter, 
509;  case  of  hernia,  475. 

Baruch,  Simon,  case  of  appendicitis,  440. 

Basedow's  disease,  336. 

Bassini's  operation  for  radical  cure  of  inguinal 
hernia,  461. 

Beck,  Carl,  operation  to  prevent  cerebral 
hernia,  242;  congenital  malformations  of 
urethra,  579. 

Beebe,  S.  P.,  parathyroid  bodies,  334;  serum  in 
goitre,  340. 

Beef  juice  for  colon  alimentation,  350. 

Beer's  keratome,  265;  straight  needle,  270. 

Benign  tumors,  differentiation  between  malig- 
nant and,  719-720. 

Bevan,  A.  D.,  lateral  curved  incision,  39S. 

Bichloride  (see  mercury)  in  lymphangitis,  85. 

Bier,  A.,  method  of  treatment  of  tuberculosis, 
756;  treatment  by  hypertemia,  757. 

Bier,  Edwin,  intrahepatic  cholelithiasis,  407. 

Bigelow,  dislocation  of  the  hip,  195;  method  of 
reducing,  197,  198. 

BiUroth's  disease,  86,  333. 

Bilharzia  hoematobia,  533. 

Biliary  calculi  in  gall  duct,  408-409;  414. 

Bistouries,  9. 

Bite,  dog,  751. 

Bladder,  515;  exstrophy  of,  516;  hernia  of,  517; 
cystocele,  517;  wounds  of,  517;  rupture  of, 
517;  gunshot  wounds  of,  519;  neoplasms  of, 
526;  stone  in,  533;  calculus  in,  534;  cystot- 
omy, suprapubic,  540;  female,  stone  in,  545; 
foreign  bodies  in,  546. 

Blake,  J.  A.,  abdominal  irrigator,  449;  hernia, 
468-472. 

Blasius'  operation  on  lower  lip,  306. 

Blepharitis,  252;  ciharis,  252;  acute,  252; 
chronic  ciliary,  252. 

Blepharophimosis,  252. 

Blepharoptosis,  252. 

Blepharospasm,  252. 

Blood-letting  in  iritis,  264. 

Blood,  pus  in,  531,  785;  vessels,  766;  bacteria 
in,  789. 

Bodine,  temporary  artificial  anus,  377;  cocaine 
infiltration,  26;  formula,  26;  abdominal 
section  for  intestinal  occlusion,  420;  opera- 
tion for  lateral  anastomosis,  438;  case  of 
hernia,  465. 

Boils,  779. 

Bone,  surgery  and  surgical  diseases  of,  144; 
caries,  of,  144;  osteomyelitis,  of,  144,  145; 
tuberculous  inflammation,  of,  145;  caries 
sicca,  of,  145;  special  fractures,  150;  hydatid 
cysts,  of,  146;  syphilitic  lesions,  of,  146;  ex- 
ostoses, of,  146;  Paget's  disease,  of,  146; 
actinomycosis,  of,  146;  acromegaly,  of,  146; 
osteomalacia,  of,  145;  rachitis,  146;  process 
of,  repair  in,  728,  766. 

Bony  new  growths  of  ear,  286. 

Boric  acid  in  gonorrhoeal  ophthalmia,  259;  in 
blepharitis,  252. 

Bougies,  Banks'  filiform,  568;  flexible,  572-573; 
urethral,  573. 

Bowleg,  664. 


Bow-saw,  10. 

Brace  for  spine,  Taylor's,  654. 

Brachial  artery,  aneurism  of,  96;  ligation  of, 

133 ;  cysts,  333. 
Bradford  and  Lovett,  hip-disease,  206. 
Brain,  compression  by  tumors  of,  237. 
Brain,   exploration  of,   238,    765;  penetrating 

wounds  of,  232;  centers,  localization  of,  233, 

234;  abscess  of,  diagnosis  of,  239,  243. 
Brandy,  19,  22. 

Brasdor's  operation  for  aneurism,  96. 
Breast,  vide  mammary  gland,  356;  tuberculosis 
.    of,  359;  carcinoma  of,  359;  sarcoma  of,  359; 
■  encephaloid  cancer  of,  360;  epithelioma  of, 

360:  tumors  of,  357;  removal  of,  360. 
Brewer,  George  E.,  pancreas,  412. 
Brickner,  W.  M.,  malposition  of  testicle,  600. 
Bristle  prong  for  removing  foreign  bodies  in 

cesophagus,  348. 
Bristow,  A.  T.,  local  anaesthesia,  797. 
Brodie's  abscess,  145. 

Bronchi,  surgery  of,  365;  foreign  bodies  in,  343. 
Bronchitis  from  foreign  bodies  in  air  passages, 

344. 
Bronchotomj^,  367. 
Brophy,  Truman  W.,  operation  for  cleft  palate, 

318,  319;  needles,  318;  periosteotomes,  10, 

320. 
Brown,  E.,  gas-oxj'gen  apparatus,  24. 
Brown,   F.  Tilden,  suprapubic  apparatus  for 

bladder  drainage,  555. 
Bruit  in  aneurism,  95,  99. 

Bryant's  test  for  fracture  in  neck  of  femur,  169. 
Bubo,  562. 
Buchanan,  operation  for  rupture  of  quadriceps 

extensor,  227. 
Buck's  method  of  treating  fracture  of  acetabu- 
lum, 169;  extension  in  facture  of  thigh,  174; 

extension  after  dislocation  of  knee,  199. 
Bunions,  679. 
Burns,  774. 

Bursitis  of  hip-joint,  205. 
Butlin,  epithelioma  of  tongue,  326. 
Button,  J.  B.  Murphy's,  410,  421. 

Caffein  in  shock,  49. 

Calcaneus,  talipes,  667. 

Calcareous  degeneration  in  tubercular  adenitis, 
86;  deposits  in  aneurism,  94. 

Calculi,  nasal,  295;  of  Steno's  duct,  307; 
urinary,  533;  in  urethra,  408-409,  414,  573. 

Calculus  in  the  bladder,  534;  of  the  pancreas, 
413. 

Calomel,  value  of,  1. 

Camphor  in  shock,  49. 

Cancer  of  oesophagus,  354,  700. 

Canthoplasty  in  gonorrhceal  ophthalmia,  259; 
in  diphtheritic  conjunctivitis,  260;  in  tra- 
choma, 259. 

Canthotomy  in  phlyctenular  keratitis,  263. 

Canula  for  trachea,  342. 

Capillary  angeioma,  89,    90;   location   of,    90. 

Capsular  cataract,  267. 

Carbuncle,  780. 

Carcinoma  of  tonsils,  329;  of  thyroid  body.  335; 
of  parotid  gland,  308:  of  the  prostate,  557;  of 
the  uterus,  628,  700;  of  larynx,  346;  of 
cesophagus,  354;  of  antrum  of  Highmore, 
310;  of  the  liver,  400,  413;  of  the  colon, 
430;  of  lung,  367;  of  stomach,  392;  of  heart, 
369;  of  mammary  land,  3,59;  of  meninges, 
231. 

Cardioclasia,  367. 


802 


INDEX 


Cardiomorphia,  367. 

Cargile  membrane  in   adhesions   of   stomach, 

390. 
Caries  of  bone,  144;  sicca,  145. 
Carotid,  arteries,  common,  aneurism  of,  102;  of 

internal  carotid,  104;  relation  of  the  veins  to, 

120;  body,  hypertrophy  of,  333. 
Carpus,  fracture  of,  165. 
Cartilage,  repair  of,  731. 
Caruncle  of  urethra,  623. 
Case,  Meigs,  suspension  apparatus,  655. 
Caseous  degeneration  in  tubercular  adenitis,  86. 
Castor  oil,  value  of,  1. 

Cataract,  varieties  of,  266;  removal  of,  268. 
Catarrh,  nasopharyngeal,  298. 
Catarrhal    pharyngitis    causing    adenitis,    85; 

inflammation  of  rectum,  500. 
Catgut  in  amputations,  50;  for  drain,  in  com- 

poimd  fractures,  182;  in  scalp  wounds,  151; 

for  ligature,  41 ;  preparation  of,  45;  for  drain- 
age, 14. 
Catherization  of  ureter,  Kelly's  method,  512, 

513;  PawUk's  method,  513,  514. 
Catheter,  Eustachian,  286;  introduction  of,  287. 
Cauda  equina,  tumors  of,  694. 
Cautery,  actual,  for  occlusion  of  arteries  and 

veins,  110;  in  haemorrhoids,  499. 
Cavernous  na^vus,  87,  SS. 
Ca^^ls,  talipes,  675. 
Celiotomy,  327. 
Centers  of  brain,  233. 
Centigrade,  796. 
Centipede,  46. 
Central  cataract,  267. 
Cephalic  vein,  45. 
Cerebral  ha?morrhage,  242. 
Cervical  glands,  tumors  of,  332;  adenitis,  85; 

superficial,  infection  of,  332. 
Cervix,    uteri,     606;    inflammation    of,     606; 

lacerations  of,  625;  amputation  of,  626. 
Chair,  Martin's,  431. 
Chalazion,  251. 

Chappell,  Walter  F.,  pharjmgotomy,  341. 
Chaps  of  lips,  304. 
Charcot  disease  of  knee-joint,  215. 
Cheeks,  lupus  of.  303. 
Chest,  woimds  of,  365. 
Cheyne-Stokes  respiration  in  cerebral  ha?mor- 

rhage,  242. 
Chin  and  head  support,  654. 
Chipault  locaUzation  of  brain  centers,  233,  234. 
Chisels,  10. 
Chloroform,  22;  selection  of,  16;  heart.  16;  in 

children,  16;  in  parturition,  16;mortahty,  16; 

skin,  22;  tissues,  15;  secretions,  17;  test  for 

purity,   22;  morphia,   22;  warming  of,   23; 

technic,  23;  cause  of  death,  23;  inhaler,  23. 
Chlorosis,  789. 

Cholecystectomy,  403,  404-407. 
Cholecystenterostomy,  410. 
Cholecystotomy,  403. 
Choledochotomy,  407-400. 
Cholelithiasis,  intrahepatic.  407. 
Chondroma,  717;  fibro-,  718. 
Chopart's  amputation  through  tarsus,  66. 
Choroiditis,  264,  282. 

Chromic  acid  in  benign  tumors  of  larjaix,  347. 
Chronic  urethritis,  follicular,  563. 
Circular  skin  flaps,  50;  skin  and  muscle  flaps, 

SO. 
Cirsoid  aneurism,  87. 

Clamp,  Smith's,  in  hemorrhoids,  499;  Roose- 
velt's, 427;  Michels,  5. 
Classification  of  tumors,  698. 


Clavicle,  fracture  of,  1.54;  dressing  for,  154,  155; 
dislocation  of,  186. 

Cleft  palate,  317;  acquired,  317;  time  to  oper- 
ate, 318;  operation  for,  318,  319. 

Clitoris,  adhesions  of,  605. 

Clubfoot,  665. 

Clubhand,  683. 

Coagulation  in  hemorrhage,  42. 

Cobra,  45. 

Cocaine,  in  removal  of  thyroid  body,  333,  340; 
in  haemorrhage  from  nose,  294 ;  in  operations 
upon  external  auditory  meatus,  285;  on  auri- 
cle of  ear,  283;  in  eye,  25;  shock,  26;  in  am- 
putation of  fingers,  52;  cure  of  hernia,  26 
preparation,  26;  in  fracture  of  patella,  176;  in 
removal  of  cysts,  229 ;  Bodine's  formula,  26 
morphia,  27;  tourniquet,  27;  small  incisions 
90 ;  thyroidectomy,  27 ;  in  removal  of  cataract, 
268;  in  ophthahnoscopy,  280;  in  deligation  of 
arteries,  106;  in  gonorrheal  ophthalmia,  259 
in  excision  of  moles,  etc.,  90;  in  removal  of 
varicose  veins,  91;  in  refraction,  275. 

Coccyx,  dislocation  of,  201;  fracture  of,  167. 

Cod-liver  oil  in  imunited  fractures,  182. 

Coffee  in  sjmcope,  45. 

Coley,  toxines  in  sarcoma  of  parotid  gland,  309; 
mixed  toxines  in  sarcoma  of  stomach,  398; 
remarks  on  lymphosarcoma,  86. 

Colles'  fracture,  164;  diagnosis  from  disloca- 
tion, 193;  dressing  for,  165;  Piloher's  method 
of  reducing,  165. 

Colon  alimentation,  in  removal  of  tongue,  327; 
flexure  of,  429;  carcinoma,  430;  in  wounds 
of  oesophagus,  331,  349,  350. 

Color-blindness,  271. 

Colostomy,  433-437. 

Common  carotid  arterj"-,  aneurism  of,  102;  liga- 
tion of,  114;  at  root  of  neck,  118. 

Common  ihac  artery,  aneurism  of,  107;  liga- 
tion of,  137,  138. 

Complete  dislocation,  185. 

Complicated  dislocation,  185. 

Compound  dislocation,  185. 

Compression  of  the  brain,  151;  by  tumors,  237. 

Concretions,  prostatic,  557. 

Concussion  of  the  brain,  151 ;  of  the  spine,  693. 

Condyle  of  jaw,  fracture  of,  153. 

Congenital,  malformations  of  urethra,  577: 
lesions  of  nose,  301;  dislocation  of  knee-joint, 
199;  fistute,  439;  tumors  of  scalp,  229; 
dislocation  of  hip,  195,  6.56;  dislocation  at 
shoulder,  681;  deformities  of  forearm,  682; 
deformities  of  fingers,  684;  deformities  of 
hands,  684. 

Conical,  stump,  in  amputations  of  humerus,  61 ; 
cornea,  263. 

Conjunctiva,  lupus  of,  260 ;  epithelioma  of,  2G0 ; 
cystic  tumors  of.  260;  xerosis  of,  260; 
phlyctenula;  of,  262,  258. 

Conjunctivitis,  acute,  258;  chronic,  258; 
circumscribed,  258;  diffuse,  2.58;  simple,  258; 
granular,  258;  folhcular,  258;  croupous,  260; 
diphtheritic,  260. 

Connective  tissue,  726;  formation  of,  726.  _ 

Council  or  buttonhole  suture,  in  gastro-jejun- 
ostomy,  387;  in  end-to-end  anastomosis,  422- 
423. 

Constriction  of  intestine,  by  bands,  414,  417; 
by  diverticula,  417. 

Contraction, ofthemouth, 306  ;Dupuytreu's,  686. 

Contused  wound,  42;  of  scalp,  232. 

Contusions  of  the  abdomen,  374;  of  the  spine, 
693. 

Coracoid  process,  fracture  of,  156. 


INDEX 


803 


Cornea,  261 ;  foreign  bodies  and  wounds  of,  261 ; 
abscess  of,  261;  ulcer  of,  262;  herpetic 
vesicles  of,  262;  phlyctenular  of,  262;  staphy- 
loma of,  263. 

Corneitis,  261. 

Coronoid  process  of  jaw,  fracture  of,  153;  of 
ulna,  163. 

Cortical  cataract,  266. 

Corns,  679. 

Cosmoline  in  treatment  of  blepharitis,  252. 

Cotton,  absorbent,  13;  sterihzation  of,  4. 

Coxitis,  203. 

Cranial  defects,  242. 

Cranium,  fractures  of,  150. 

Crepitus  in  fracture  of  bones,  147. 

Crinohne  for  bandage,  29. 

Critchett's  operation  for  staphyloma,  263. 

Croupous  conjunctivitis,  260. 

Crushing  for  occlusion  of  arteries  and  veins, 
110,  ill. 

Crystalline  lens,  266. 

Curettage  of  the  uterus,  627. 

Curvature  of  the  spine,  63S;  lateral,  638;  rotarj^ 
lateral,  638,  641. 

Cushing,  H.  W.,  mattress  suture,  382;  suture  in 
gastrectomj',  397,  424. 

.Cushing,  Hari'ey,  exploration  of  brain,  238; 
fracture  of  base  of  skull,  241 ;  operation  for 
excision  of  Gasserian  ganglion,  247. 

Cyclitis,  265. 

Cyphosis,  638. 

Cystic  goitre,  335;  drainage  of,.  337;  tumors  of 
neck,  333;  tumors  of  tongue,  325;  tumors  of 
tonsils,  329;  tumors  of  larj'nx,  346;  tumors 
of  conjunctiva,  260;  formations  of  lower  jaw, 
312;  tumors  of  lips,  304. 

Cysticercus  of  tongue,  325. 

Cystitis,  520-523. 

Cystocele,  517. 

Cystoma  of  parotid  gland,  308. 

Cystotome,  269. 

Cystotomy,  suprapubic,  540. 

Cysts,  congenital  of  scalp,  229;  dermoids,  229; 
multilocular,  229;  sebaceous,  229;  of  nwm- 
maty  gland,  359;  of  nipple,  356;  brachial. 
333;  dentigerous,  316;  of  eyelids,  251;  of 
kidney,  506;  of  scrotum,  588;  of  ovar^^ 
dermoid,  636,  713;  of  spleen,  412;  hydatid  of 
liver,  401;  mucous,  714;  serous,  714. 

Dacryo-cystitis,  257. 

Dacryoadenitis,  257.  . 

DacryoUths,  257. 

Daviels'  curette,  261;  spoon,  269. 

Davis,  D.  B.,  case  of  splenectomy,  412. 

Davy's  lever  in  aneurism  of  external  iliac 
artery,  107. 

Dawbam's  sequestration,  16,  17,  20,  28;  in 
removal  of  thyroid  body,  334,  337;  in  gun- 
shot wounds  of  skuU  and  brain,  233;  in  re- 
moval of  parotid  gland,  308;  in  formidable 
operations  about  mouth,  314;  in  complete 
removal  of  external  carotid  arterj',  330. 

Deaver,  J.  B.,  method  of  treatment  for  wounds 
of  the  ureter,  509;  case  of  appendicitis,  440, 
445;  abdominal  incision,  373. 

Defects,  cranial,  242. 

Deformities,  of  the  uterus,  611;  of  the  spinal 
column,  638;  of  the  lower  extremity,  656; 
of  the  laiee,  660,  661 ;  of  the  toes,  676-677;  of 
upper  extremity,  681 ;  congenital,  of  the  fore- 
arm, 682;  congenital,  of  the  fingers,  684; 
congenital,  of  the  hands,  084. 

Degrees,  796. 


Deligation  of  arteries  {vide  ligation)  for  aneur- 
ism, 96. 

Deltoid,  paralysis  of,  681. 

Dench,  introduction  of  Eustachian  catheter, 
287;  myringotomy,  289;  location  of  mastoid 
antrum,  29  i;  removal  of  adenoids,  298. 

Dental  forceps,  315. 

Dentigerous  cysts,  316. 

Dermoid  cysts,  of  mammary  gland,  359;  of 
ovary,  636;  of  scalp,  229. 

Deschamp's  needles,  320. 

Desmarres'  retractors,  261. 

Destructive  osteo-arthritis  of  knee-joint,  213. 

Detachment  of  retina,  271. 

Detmold's  method  of  controlling  ha;morrhage, 
40,  47. 

De  Vilbiss,  forceps  in  trephining,  236;  bone 
forceps,  11. 

Diagnosis  of  sj'philis,  769. 

Diaphragm,  hernia  of,  456. 

Dieffenbach,  hip-joint  amputation,  75. 

Diet  list,  2. 

Differentiation  between  benign  and  malignant 
tumors,  719-720. 

Diffuse  keratitis,  261. 

Dilating  urethrotome  (Otis'),  567. 

Diphtheria,  745,  747. 

Diphtheritic  conjunctivitis,  260. 

Diplopia,  278. 

Disarticulation,  at  tarso-metatarsal  joint,  64;  at 
tibio-tarsal  joint,  68,  69;  of  finger  phalanges, 
52;  of  toes,  63;  at  elbow-joint,  58,  .59;  at 
metacarpo-phalangeal  joint,  54;  at  carpo- 
radial  joint,  55,  56;  at  astragalus,  67;  at 
calcaneus,  67;  at  hip-joint,  75,  76,  77;  at 
knee,  73,  74;  at  metatarsal  joint,  64;  at 
shoulder-joint,  61,  62;  carpo-metacarpal 
joint,  55. 

Discission  of  cataract,  270. 

Diseases,  of  ankle-joint,  215;  of  l-oiee-joint,  212; 
of  shoulder-joint,  216;  of  hip-joint,  203;  of 
bone,  144;  of  special  joints,  203;  of  joints, 
202;  of  lips,  302;  of  fingers,  688;  surgical, 
721;  of  foot,  755;  of  mouth,  755;  venereal, 
758. 

Dislocations,  traumatic,  185;  pathological,  185; 
congenital,  185;  complete,  185;  simple,  185; 
comphcated,  185;  compound,  185;  recent, 
185;  ancient,  185;  primitive,  185;  secondary, 
185. 

Dislocation,  of  anlde-joint,  200;  of  tibio-tarsal, 
200;  of  patella,  200;  of  hip,  194-198;  of 
phalanges  of  fingers,  193;  of  knee-joint,  199; 
of  inferior  maxilla,  185;  at  elbow,  190-192; 
of  head  of  radius,  186;  of  radius  and  ulna  at 
elbow,  191-193;  of  wrist-joint,  193;  of  meta- 
carpal bones,  193;  of  clavicle,  186;  at  shoul- 
der-joint, 186;  subglenoid,  186;  subcoracoid, 
186;  subclavicular,  186;  subspinous,  186; 
subacromial,  190;  of  vertebrte,  201;  of  con- 
dyles of  occipital  bone,  201;  of  ribs,  201;  of 
pelvis,  201 ;  of  coccyx,  201 ;  of  tibia  at  lower 
end,  200;  of  fibula, '201;  of  bones  of  tarsus, 
201;  of  astragalus.  201;  of  phalanges  of  toes, 
201;  of  metatarsal  bones,  201;  congenital,  of 
hip,  656;  at  the  shoulder,  6S1;  of  the  spine, 
693. 

Displacement,  of  the  uterus,  611;  of  the  spleen, 
412;  of  the  liver,  402. 

Dissecting  aneurism,  93,  94. 

Distichiasis,  256. 

Diverticula,  of  oesophagus,  354;  constriction 
by,  417. 

Divulsion  of  urethral  stricture,  567. 


INDEX 


Dobell's  solution  in  ozfena,  296. 

Dog-bite,  751. 

Dorsalis  pedis  artery,  ligation  of,  143;  aneurism 

of,  108. 
Double,  harelip,  324;  penis,  51.5,  516;  Wood's 

method  of  treatment  of,  517. 
Dowd,  cysts  of  mesentery,  413. 
Downey's  op.  table,  6,  8;  in  fracture  of  femur, 

170. 
Doyen,  holding  clamps,  386. 
Drain,  14;  in  compound  fracture,  182;  in  scalp 

wounds,  153. 
Drainage,  of  cystic  goitre,  337;  of  gall  bladder, 

404;  in  amputations,  51;  of  wounds,  43. 
Dressing,  for  fracture  of  clavicle,  154,  155;  for 

CoUes'  fracture,  165. 
Drills,  1 1 ;  in  exsection  of  knee-joint,  221 ;  of 

ankle-joint,  222;  Wyeth's,  16S. 
Drooping  of  ears,  283. 
Drum,  for  testing  edge  of  instruments,  266;  of 

ear,  perforation  of,  289. 
Dry  sjmovitis,  203. 
Duct,  parotid,  306. 
Dugas,  diagnosis  of  dislocated  humerus,   187; 

diiferentiation  between  fracture  and  disloca- 
tion of  humerus,  156. 
Duodeno-gastroplasty,  390. 
Duodenum,  surgery  of,  398;  ulcer  of,  398;  per- 
forations of,  399. 
Duplay,  congenital  malformations  of  urethra, 

577. 
Dupuytren's  contraction,  686. 
Dura  mater,  sarcoma  of,  231;   carcinoma   of, 

231. 

Ear,  283;  foreign  bodies  in,  285;  double  hoolc 
for,  284;  forceps,  284;  probe,  284;  external 
auditory  canal,  284;  intertrigo  of,  283;  lesions 
of,  285;  vegetable  parasites,  285;  impacted 
cerumen,  285;  drooping  of,  283;  auricle  of, 
283;  adhesions  to  scalp,  283;  benign  neo- 
plasms of,  283 ;  angeioma  of,  283;  epithelioma 
of,  283;  hypertrophy  of,  283. 

Earle,  method  of  treatment  of  haemorrhoids, 

^  499. 

Ecraseur  in  ablation  of  tongue,  327. 

Ectocardia,  367. 

Ectopic  gestation  and  pregnancy,  637. 

Ectropion,  253. 

Eczema,  of  rectum  and  anus,  478;  of  the  scro- 
tum, 588;  of  nipple,  356;  of  eyelids,  256. 

Effusion  into  Icnee-joint,  212. 

Eggs  for  colon  alimentation,  350. 

Elbow,  fractures  at,  147. 

Elbow-joint,  amputation  at,  58,  59;  disarticula- 
tion at,  58,  59;  synovitis  of,  217;  dislocation 
of,  190-192;  prognosis  of,  191. 

Electric  saw,  236;  trephine,  236. 

Elephantiasis  of  scrotum,  588,  605. 

Emmetropia,  273. 

Encephaloid  cancer  of  breast,  359. 

Encephalocele,  231. 

Enchondroma,  of  lower  jaw,  312;  of  larynx,  346 ; 
of  tongue,  326;  of  parotid  gland,  308; 
of  mammary  gland,  358;  testis,  599,  717. 

Encysted  fibroma  of  lower  jaw,  312. 

Endarteritis,  87. 

Endo-aneurismorrhaphy,  97. 

Endocer^dcitis,  606;  tuberculous,  606. 

Endometritis,  607;  puerperal,  60S. 

Endo-phlebitis,  86. 

Endoscope,  in  gastric  ulcer,  382;  Klotz  urethral, 
564. 

Endostitis,  144. 


End-to-end  anastomosis,  421. 

Enteroliths,  414. 

Entropion,  255. 

Enucleation  of  eye,  265. 

Epicanthus,  256. 

Epididymis,  tuberculosis  of,  596,  598. 

Epididymitis,  561,  596. 

Epilation  of  eyelashes,  252. 

Epilepsy,  surgical  treatment  of,  244. 

Epiphora,  257. 

Epistaxis,  2D4. 

Epithelioma,  diagnosis  from  lupus  ^allgaris,  304 ; 
of  eyelids,  251;  of  ear,  283;  of  nose,  296;  of 
breast,  359;  of  nipple,  356;  of  scrotum,  589, 
702;  of  conjmictiva,  260;  of  oesophagus,  3.54; 
of  lips,  302;  of  tongue,  326. 

Equina  (cauda),  694. 

Equinus,  talipes,  665. 

Erdmann,  J.  F.,  case  of  appendicitis,  441. 

Erysipelas  of  scrotum,  588,  744. 

Erythema  of  rectum  and  anus,  478. 

Eserine  after  excision  of  cataract,  269. 

Esmarch's,  bandage,  12,  29,31 ;  in  osteomyelitis, 
145;  in  fractures  about  elbow,  158;  for  re- 
ducing swelling,  160;  in  aneurism,  107,  108; 
screen,  20,  23;  bandage  for  eye  and  upper  lip, 
37;  head  and  face  hood,  38;  in  ha?morrhage, 
40;  bandage  in  exsection  of  shoulder-joint, 
224;  splint  for  exsection  of  wrist,  226;  in 
amputations,  48,  49;  in  exarticulation  at 
shoulder-joint,  63;  method  of  amputating 
at  carpo-metacarpal  joint,  55;  bandage  in 
amputation  at  hip-joint,  76;  in  exsection  of, 
224. 

Esophoria,  278. 

Ether,  18;  with  nitrous  oxide,  16,  25;  morphia, 
16;  in  children,  16;  mortality,  16;  selection  of, 
16;  heart,  21;  drop  method,  19,  20;  warm- 
ing, 18;  effect  on  temperature,  18;  adminis- 
tration of,  18,  25;  nervous  system,  IS;  in- 
haler, 18 ;  in  brain  surgery,  234. 

Eustachian  catheter,  286;  introduction  of,  287. 

Eve,  F.  S.,  shortening  gastrohepatic  omentum, 
391. 

Everbusch,  operation  for  ptosis,  253. 

Examination  of  patient,  2. 

Excision  (mde  exsection) ,  of  Gasserian  ganglion, 
245,  247;  of  uvula,  317;  of  knee-joint,  199;  of 
the  intestine,  420. 

Exophoria,  278. 

Exophthalmic  goitre,  336. 

Exostoses,  146;  of  the  skull,  146;  after  fractures, 
146. 

Exostosis  of  skull,  231. 

Exploration  of  brain,  238. 

Exsection  (vide  excision) ,  of  wrist-joint,  225;  of 
shoulder-joint,  222;  of  knee-joint,  219;  of 
hip-joint,  217;  of  elbow,  224;  of  ankle-joint, 
221;  of  metacarpo-phalangeal  joints,  227;  of 
inter-phalangeal  joints,  227;  of  joints,  217. 

Exstrophy  of  the  bladder,  516. 

External  auditory  canal,  286;  lesions  of,  285; 
carotid  arterj^,  branches  of,  121;  anatomy  of, 
121;  ligation  of,  121,  122;  aneurism  of,  103; 
iliac  artery,  anatomy  of,  138;  ligation  of,  138; 
urethrotomy,  566;  modified,  570. 

Extraction  of  teeth,  315. 

Extremity,  deformities  of  lower,  656;  deformi- 
ties of  upper,  681. 

Eye,  wounds  of  lids,  251 ;  contusions  about,  251 ; 
new  formations,  251 ;  capillary  angeioma,  25 1 , 
768. 

Eyelashes,  epilation  of,  252. 

Eyelids,  affections  of,  251;  restoration  of,  256. 


INDEX 


805 


Face,  contusions  of,  302;  lacerated  wounds  of, 
302;  punctured  wounds  of,  302;  shot  wounds 
of,  302;  incised  wounds  of,  302;  horns  of,  229. 

Facial  artery,  ligation  of,  125;  paralysis,  249. 

Fahrenheit,  796. 

Fallopian  tubes,  infection  of,  610. 

False,  aneurism,  93,  94;  laiot,  41. 

Fascia  palmar,  6S6. 

Fecal  fistula,  438. 

Females,  gonorrhoea  in,  563,  603 ;  genito-urinary 
organs  in,  602. 

Femoral  artery,  anatomy  of,  139;  ligation  of, 
139,  140;  aneurism  of,  107;  hernia,  456,  465- 
468. 

Femur,  fracture  of,  168. 

Ferguson,  crushing  clamps,  394. 

Fibroma,  of  antrum  of  Highmore,  310;  of 
tonsils,  329,  714;  of  nipple,  356;  of  mammary 
gland,  3.58;  of  heart,  369;  of  lower  jaw,  312; 
of  tongue,  326;  of  parotid  gland,  308;  of  lips, 
304. 

Fibro-chondroma,  718. 

Fibroids  of  the  uterus,  628. 

Fibromata,  of  larynx,  346;  of  nose,  295. 

Fibro-myxoma  of  larjTix,  312. 

Fibula,  dislocation  of,  201;  fracture  of,  178. 

Filaria  sanguinis  hominis,  86. 

Fihform  bougies.  Banks',  568. 

Fingers,  amputation  of,  51,  52;  disarticulation 
of,  52;  bandage  for,  31,  32;  web-,  685;  snap-, 
687;  jerk-,  687;  lesions  of,  687;  tendon  suture 
of,  687;  real  diseases  of,  688;  phlegmon  of, 
689;  amputation  of,  692. 

Fischer's  double  spica  bandage,  35;  for  breast, 
35. 

Fissure,  of  hps,  304;  of  nipple,  356;  of  nares, 
295;  of  anus,  482. 

Fistula,  of  the  anus,  479;  fecal,  438;  operation 
for,  480-481;  urinary,  574;  urethral,  574; 
urethro-perineal,  operation  for,  575,  576; 
vesico-vaginal,  623-624;  of  oesophagus,  354; 
salivary,  306. 

Fistula;,  of  scrotum,  589;  congenital,  439; 
brachial,  333. 

Fitz,  R.  H.,  appendicitis,  440. 

Flap,  modified  circular  skin,  .50;  circular  skin 
and  muscle,  61;  circular,  50,  57;  modified 
circular  in  amputation  of  leg,  70 ;  long  plantar 
and  short  dorsal,  56;  flap  in  amputation  at 
knee,  73;  in  hip-joint  amputation,  78,  79; 
combination  skin  and  muscle  flap,  50;  long 
plantar  in  amputation  of  toes,  63. 

Flat-foot,  674. 

Flaxseed  poultice  in  honphangitis,  85. 

Flexible  bougies,  572-573. 

Flexure  of  the  colon,  429. 

Fluhrer,  W.  F.,  swing,  740. 

Fluoroscope  in  dislocation  at  elbow,  191. 

Follicular  conjunctivitis,  258. 

Foot  disease,  755. 

Forbes,  amputation  at  tarsus,  66. 

Forceps,  for  removing  foreign  bodies  from  the 
trachea,  345;  dental,  315;  haemostatic,  12; 
dissecting,  12;  rongeur,  11;  suture,  12; 
sequestrvim,  12;  for  iris,  268. 

Forearm,  fracture  of,  161;  congenital  de- 
formities of,  682. 

Foreign  bodies,  in  oesophagus,  347;  in  pharynx, 
347;  in  cornea,  261;  in  the  ear,  285;  in  the 
nose,  294;  in  bladder,  .546;  in  urethra,  573;  in 
intestines,  414;  in  stomach,  379. 

Formalin  in  pleural  empyema,  366. 

Formation  of  connective  tissue,  726. 

Foster's,  cataract,  267. 


Fowler  solution  in  Billroth's  disease,  333; 
posture  in  traumatic  affections  of  viscera, 
377. 

Fracture,  146;  of  sternum,  165;  of  ribs,  165;  of 
vertebrfe,  166;  of  sacrum,  167;  of  coccyx, 
167;  of  OS  innominatum,  167;  of  ulna,  161 ;  of 
radius,  163;  Colles',  164;  of  cranium,  150;  of 
base  of  skull,  152;  of  nasal  bones,  152;  of 
malars,  152;  plaster-of-Paris  dressing  for, 
148;  process  of  repair  in,  148;  special,  150; 
partial,  146;  green-stick,  147;  complete,  147; 
transverse,  147;  oblique,  147;  longitudinal, 
147;  single,  147;  double,  147;  multiple,  147; 
simple,  147;  comminuted,  147;  compound, 
147,  183;  complicated,  147;  impacted,  147; 
ununited,  147,  181;  from  direct  violence,  147; 
from  indirect  violence,  147;  symptoms  and 
diagnosis  of,  147;  prognosis  of,  147;  at  the 
elbow,  147;  of  eoronoid  process  of  ulna,  163; 
box,  ISO;  of  the  spine,  693;  classification  of, 
146;  review  of,  161;  of  neck  of  femur,  168;of 
patella,  175;  of  leg,  178;  of  tibia,  178;  of 
fibula,  178;  Pott's  fracture,  178;  of  tarsus, 
181;  of  OS  calcis,  181;  of  astragalus,  181;  of 
metatarsal  bones,  181;  of  phalanges  of  foot, 
181 ;  of  zygoma,  152 ;  of  superior  maxilla,  152 ; 
of  lower  jaw,  153;  of  angle  of  jaw,  153;  of 
ramus  of  jaw,  153;  of  eoronoid  process  of 
jaw,  153;  of  larynx,  153;  of  hyoid  bone,  154; 
of  clavicle,  154;  of  scapula,  155;  of  acromion 
process,  1.55;  of  coracoid  process,  156;  of 
glenoid  process,  1.56;  of  humerus,  156;  of 
carpus,  165;  of  metacarpus,  165;  of  phalanges 
of  hand,  165. 

Frank,  gastrostomy,  352. 

Friction  knot,  41. 

Frontal  sinuses,  abscess  of,  230. 

Frostbite  as  cause  of  epithelioma  of  ear,  283, 
779. 

Fuller,  Eugene,  treatment  of  chronic  vesiculitis, 
559. 

Functional  disturbances  of  thyroid  body,  336. 

Fundus  of  eye,  examination  of,  280. 

Furuncle,  779. 

Fusiform  aneurism,  93,  94;  reconstructive 
arterioplasty  in,  97;  cataract,  267. 

Gall  bladder.  403;  drainage  of,  404;  Hockey's 
valvular  method  of  closing,  404. 

Gall  ducts,  403;  removal  of  stone  from,  408; 
biliary  calculi  in,  408-409. 

Gait's  trephine,  12,  151. 

Ganglion,  691,  692. 

Gangrene  from  foreign  bodies  in  air  passages, 
,344;  hospital,  753,  781;  senile,  783;  pulmo- 
nary, 366. 

Gant's,  incision  for  ablation  of  tongue,  327; 
treatment  of  fissure  of  anus,  482. 

Gas-oxygen  inhaler,  24;  gas-ether  inhaler,  18. 

Gasserian  ganglion,  excision  of,  245,  247. 

Gastrectomy,  393. 

Gastric,  ulcer,  381 ;  perforations,  399 ;  lavage,  2. 

Gastro-duodenostomy,  389. 

Gastro-enterostomy,  389. 

Gastro-jejunostomy,  383;  landmarks  of,  384; 
operation,  384. 

Gastroplication,  391. 

Gastroptosis,  390. 

Gastro-pylorectomy,  390. 

Gastrostomy,  Sebauijew  and  Frank,  for  stric- 
ture of  oesophagus,  352. 

Gastrotomy  for  removal  of  foreign  bodies  in 
stomach,  379. 

General  suppurative  peritonitis,  449. 


806 


INDEX 


Genito-urinary  organs,  502;  in  females,  602. 

Genu,  valgum,  660-661;  varum,  660,  664; 
Macewen's  operation  for,  663. 

Giant-cell  sarcoma,  707. 

Gibney,  Pott's  disease,  656. 

Gigli,  wire  saw,  10;  in  exsection  of  hip-joint, 
218. 

GUa  monster,  46. 

Girdner,  J.  H.,  skin-grafting,  777. 

Gland,  parotid,  removal  of,  307;  lachiymal, 
257;  parotid,  306;  submaxillary,  309;  lym- 
phatic, infection  of,  85;  tuberculosis  of,  85. 

Glanders,  754. 

Glass  cylinder,  Sims',  607. 

Glaucoma,  265;  simplex,  282;  iridectomy  for, 
266. 

Gleet,  563. 

Glenoid  process,  fracture  of,  156. 

Glossitis,  325. 

Glottis,  spasm  of,  in  aneurism,  94. 

Gloves,  hop-pickers,  3;  rubber,  3. 

Gliige,  granular  corpuscles  in  goitre,  335. 

Gluteal  artery,  ligation  of,  138;  aneurism  of, 
107;  hernia,  456. 

Goitre,  333;  cystic,  335;  simple,  334;  sohd  form, 
334;  semi-solid,  335. 

Gonorrhoea  in  females,  563,  603,  758-761. 

Gonorroehal,  infection  of  the  rectum,  500; 
proctitis,  562;  ophthalmia,  259,  562;  rheuma- 
tism, 562. 

Goodwillie's  mouth-gag,  19. 

Graefe's,  speculum,  268;  fixation  forceps,  268; 
linear  knife,  268. 

Grafting,  skin-,  775-777. 

Graham,  ulcer  of  duodenum,  398. 

Grant,  H.  H.,  enterotome,  438. 

Grant,  W.  W.,  case  of  appendicitis,  440. 

Granular  conjunctivitis,  258. 

Grave's  disease,  336. 

Green,  goitre,  340. 

Gritti,  amputation  at  knee,  74. 

Groin,  inguinal  adenitis  of,  562. 

Groove  director,  12. 

Gross'  speculum  oris,  19. 

Growths,  new  classification  of,  698. 

Gruening's  depilating  forceps,  256. 

Guiteras,  Ramon,  dislocation  of  testicle,  601. 

Gumma  of  heart,  369. 

Gunshot  wounds,  of  the  bladder,  46;  A.  C. 
Walker's  operation  for,  519;  treatment  of, 
47;  of  skuU  and  brain,  232;  of  neck,  331;  of 
joints,  203. 

Gwathmey's,  ether  inhaler,  18;  warm  vapor  ap- 
paratus, 18. 

Hajmatobia,  Bilharzia,  533. 

Haematology,  785. 

Hfematoma  of  scrotum,  589. 

Hsemorrhage,  40 ;  classification,  40 ;  primary,  40 ; 
secondary,  40;  arrest  of,  40;  Esmarch's 
bandage,  40;  method  of  Detmold,  40;  hot  and 
cold  apphcations  in,  40;  torsion,  40,  41; 
ligature,  40,  41 ;  artery  forceps,  40 ;  retraction, 
41;  catgut,  silk  and  linen,  41;  lateral  ligature 
in,  41;  reef  Imot,  41;  false  knot,  41;  friction 
knot,  41;  aneurism  needle,  42;  coagulation, 
syncope  in,  45;  in  removal  of  arterial  angeio- 
ma,  87;  after,  internal  urethrotomy,  568;  of 
the  spine,  693-694 ;  arrest  of,  in  major  injuries, 
48;  as  cause  of  shock,  49;  in  hip-joint  am- 
putation, 75;  in  fracture  of  nasal  bones,  152; 
cerebral,  242;  from  nose,  294. 

Hemorrhoids,  495;  T\Tiitehead's  operation  for, 
497;  L.  S.  Pilcher's  method  of  treatment  of, 


498,  499 ;  Earle's  method  of  treatment  of,  499 ; 

A.   B.   MitcheU's  method,   499;  clamp  and 

cautery,  operation  for,  499. 
Hagedorn  needle,  45. 
Hair  on  hps,  304. 

Hall,  Richard,  case  of  appendicitis,  440. 
Hallux  valgus,  677;  varus,  677. 
Halstead,  A.  E.,  case  of  hernia,  455. 
Halsted,  W.  S.,  case  of  hernia, -463;  inguinal 

hernia,  797. 
Hamilton's  long  splint  in  fracture  of  thigh,  174 ;  . 

bandage   for   fracture    of   lower   jaw,    153; 

olecranon  splint,  162;  splint  for  patella,  177; 

long  splint  in  hip  disease,  207. 
Hancock,  T.  H.,  apparatus  for  applying  plaster, 

170. 
Hand,  amputation  of,  51,  56;  bandages  for,  31, 

32;  disinfection  of,  3;  congenital  deformities 

of,  684;  phlegmon  of,  689;  tuberculosis  of, 

691;  cleansing  of,  798. 
Harelip,  321;  double,  324;  operation  for,  321. 
Harrington's  solution,  798. 
Harris,  tooth  forceps,  316. 
Hartley,   operation   for   excision  of   Gasserian 

ganglion,    247;    apparatus    for    trephining, 

236. 
Head  and  chin  support,  654. 
Heart,  aneurism  of,  369;  tumors  of,  369;  foreign 

bodies  in,  369;  wounds  of,  367;  surgery  of, 

367;  stab  wounds  of,  368;  massage  of,  22; 

paralysis  of,  16,  766. 
Hemeralopia,  271. 
Hemianopsia,  271. 
Hepatic  abscess  of  the  liver,  401. 
Hernia,  452,  455;  inguino-properitoneal,  455; 

infantile,  455;  femoral,  465-468,  486;  ventral, 

456;     diaphragmatic.     456;     gluteal,     456; 

obturator,    456,    474;    lumbar,    456,    474; 

vaginal,  456,  474;  perineal,  458;  pudenal,  458, 

474;  inguinal,   485;  Bassini's  operation  for 

radical  cure  of,  461;  strangulated  inguinal, 

464;  umbilical,  456;  Mayo's  operation  for, 

472-473;  of  bladder,  517;  of  labium,  604;  of 

ovary,  604;  of  spleen,  412;  cerebri,  231;  of 

stomach,  391. 
Herniotomy  with  local  ancesthesia,  465. 
Herpes  of  penis,  585. 
Heterophoria,  278. 
Hey,  modification  of  Lisfranc's  amputation  of 

foot,  66. 
Highmore,  antrum  of,  affections  of,  309. 
Hill,  L.  L.,  stab  wound  of  heart,  .368. 
Hip,  congenital  dislocation  of,  656;  osteotomy 

at,  658. 
Hip-joint,  Sayre's  exsection  of,  217;  arthritis  of, 

203;  causes  of,  204;  dislocation  of,  194,  195, 
196,  197;  prognosis  of,  199;  disease  of,  203; 

amputation  at,  Wyeth,  75,  76,  77. 
Hodgkin's  disease,  86. 
Holding  straps,  20. 

Holmes'  elastic  ball  for  compression  in  aneur- 
ism, 107. 
Holmgren's  colored  woolen  threads,  271. 
Holt,  L.  Emmet,  intussusception,  415. 
Homatropine  hydrobromate,  in  refraction,  275; 

in  ophthalmoscopy,  280. 
Hop-picker's  gloves,  3. 
Hordeolum,  251. 
Horns  of  scalp,  229;  of  face,  229. 
Horsehair,  for  suture,  4;  sutures  in  wormds  of 

face,  302. 
Horsley's  sterile  wax  in  trephining,  236. 
Hospital  gangrene,  753. 
Hour-glass  stomach,  389. 


INDEX 


807 


Humerus,  fracture  of  surgical  neck  of,  156;  of 
shaft,  157;  at  elbow,  158;  fracture  of  ex- 
ternal condyle,  159;  of  internal  condyle,  159; 
paralysis  from  fracture  of,  147;  dislocation 
of,  186;  general  considerations  of,  190;  sec- 
tion at  anatomical  neck,  60. 

Humphrey's  operation  for  amputation  of  penis, 
583. 

Hunter's  method  of  ligating  in  aneurism,  96. 

Hyalitis,  270. 

Hydatid  cj^sts,  of  mammary  gland,  359;  of 
thyroid  body,  341;  in  bone,  146. 

Hydrocele,  590,  591;  Volkmann's  operation  for, 
592;  tunica  funiculi  of,  592;  Levis'  operation 
for,  591. 

Hydrocephalus,  231. 

Hydronephrosis,  503,  504. 

Hydrophobia,  751. 

Hj'oid  bone,  fracture  of,  154. 

Hifpera-mia,  Bier's  method  of  treatment  of,  756. 

Hypermetropia,  273. 

HjTJerostosis  of  skuU,  231. 

Hyperphoria,  278. 

Hypertrophy,  of  tongue,  325;  of  lips,  304;  of 
mammary  gland,  357;  of  prostate,  547-549; 
treatment  of,  549,  550;  of  auricle  of  ear,  283; 
of  thjToid  body,  334. 

Hyperthyroidism,  336. 

Hypophosphites  of  hme  and  soda  in  ununited 
fractures,  182;  in  hip-disease,  210. 

Hypopyon.  261. 

Hypospadias,  577;  operation  for,  578,  579. 

Hysterectomy,  abdominal,  631;  during  preg- 
nane}', 633;  vaginal,  634. 

Hysterotomy,  631. 

Idiopathic  choroiditis,  264. 

Imperforate,  hymen,  623;  anus,  438. 

Incised  wound,  42;  of  neck,  331. 

Incision,  in  exsection  of  knee-joint,  219;  of  hip- 
joint,  217;  of  ankle-joint,  221;  of  Shrapnell's 
membrane,  289. 

Incontinence  of  urine,  525;  H.  Marion-Sims' 
treatment  of,  525. 

Index-finger,  amputation  of,  53. 

Infantile  hernia,  455. 

Infection,  of  mastoid  bone,  291;  of  Fallopian 
tubes,  (510. 

Inferior  dental  nerve,  resection  of,  114. 

Inferior  maxilla,  312;  fracture  of,  153;  anky- 
losis of,  115;  dislocation  of,  185;  reduction  of 
dislocation  of,  186. 

Inflammation,  503;  of  joints,  202;  of  kidnevs, 
503;  of  cervix  uteri,  606,  621. 

Inflation,  of  tjTnpanum,  286. 

Ingrowing  nail,  679,  680. 

Inguinal,  adenitis  of  groin,  562;  hernia,  458; 
Bassini's  operation  for  radical  cure  of,  461. 

Inguino-properitoneal  hernia,  455. 

Inhaler,  for  ether,  18;  for  chloroform,  23;  of 
Ormsby,  19;  of  Allis,  25;  for  gas-ether,  18; 
for  gas-oxygen,  24;  sterilization  of,  22. 

Inherited  syphilis,  772.    ' 

Injection  of  alcohol  for  trifacial  neuralgia,  245. 

Innominate  artery,  aneurism  of,  100,  102; 
anatomy  of,  113;  ligation  of,  113,  114. 

Instruments,  surgical,  8-13;  sterilization  of,  13. 

Intercostal  arteries,  anatomy  of,  136;  ligation 
of,  136. 

Internal,  iliac  artery,  anatomy  of,  138;  ligation 
of,  138;  carotid  artery,  aneurism  of,  104; 
anatomy  of,  120;  ligation  of,  120;  rectus 
muscle,  tenotomy  of,  272;  pudic  artery, 
ligation  of,  139;  mammary  artery,  aneurism 


of,  106;  relations  of,  129;  ligation  of,  131; 
maxillary  artery,  anatomy  of,  126;  ligation 
of,  126. 

Internal,  urethrotomy,  566;  hoemorrhage  after, 
568;  modified,  569;  ojsophagotomy,  351; 
jugular  veins,  hgation  of,  126. 

Interphalangeal,  amputations  of  fingers,  52; 
joints,  exsection  of,  227. 

Intertrigo  of  ear,  283. 

Intestinal  perforations,  closure  of,  376;  ob- 
struction, 414;  anastomosis,  420. 

Intestines,  foreign  bodies  in,  414;  intussuscep- 
tion, 415;  strangulation  and  occlusion,  ab- 
dominal section  for,  419;  obstruction  of,  414; 
condition  of,  417;  neoplasms  of,  418;  stricture 
of,41S;  excision  of,  420;  resection  of,  421-424; 
carcinoma  of,  4,30. 

Intrahepatic  cholelithiasis,  407. 

Intravenous  infusion,  in  S3'ncope,  45;  apparatus 
for,  44,  45;  salt  solution  for,  45. 

Intussusception,  415. 

Inversion  of  the  uterus,  627. 

Involucrum,  144. 

Iodide  of  potassium  in  treatment  of  aneurism, 
95. 

Iridectomy,  for  glaucoma,  266 ;  for  staphyloma, 
263,  269. 

Iris,  forceps,  265;  scissors  for,  266. 

Iritis,  264. 

Irrigator,  Blake's  abdominal,  449. 

Jackson's  exploring  dilator  in  abscess  of  the 
brain,  239. 

Jacobi,  A.,  gastric  ulcer,  381. 

Jaeger's  angular  keratome,  265;  test-types,  277. 

Jarvis'  snare,  295;  wire  loop  in  neoplasms  of 
larynx,  347. 

Jaw,  309;  upper,  removal  of,  311. 

Jerk-finger,  687. 

Joints,  dislocation  of,  185;  diseases  of,  202; 
inflammation  of,  202;  tuberculosis  of,  202;  of 
hip,  203;  exsection  of,  217;  766;  shoulder, 
dislocation  of,  186,  190;  wrist,  dislocation  at, 
193;  hip,  dislocation  at,  194,  197. 

Jones,  Wharton,  operation  for  ectropion,  254. 

Jugular  vein,  ligation  of,  114. 

Kangaroo  tendon,  4,  6. 

Keen,  W.  W.,  aspiration  of  ventricles  of  brain, 
-243. 

Kelly,  H.  A.,  method  of  ureteral  catherization, 
512,  513;  treatment  of  lacerations  of  vagina 
and  perinajum,  613;  complete  rupture  of 
recto- vaginal  septum,  615-618;  caruncle,  623. 

Keloid,  719. 

Keratitis,  261;  traumatic,  201;  diffuse,  261. 

Keratome,  Jaeger,  265. 

Keyes',  stylet,  524;  case  of  urinary  fistula  com- 
municating with  urethra,  576. 

Kej'hole  saw,  10. 

Kidneys,  wounds  of,  502;  inflammation  of,  503; 
pyelitis,  pyelonephritis,  hydronephrosis,  503, 
504;  nephrolithiasis,  stone  in,  505;  cysts  of, 
506;  tumors  of,  506;  movable,  506,  507; 
floating,  506,  507;  nephrectomy,  508,  767. 

Klotz's  urethral  endoscope,  564. 

Knapp's  entropion  forceps,  255. 

I-inee,  deformities  of,  660,  661 ;  laiock-,  660-663 ; 
ankylosis  at,  665. 

Knee-joint,  amputation  at,  73;  exsection  of, 
219;  acute  s>'no"\itis  of,  212;  chronic  effusion 
into,  212;  Charcot's  disease  of,  215;  disloca- 
tion of,  199. 

Knives,  9. 


INDEX 


Knock-lmee,  660-63. 

Knot,  reef,  41;  false,  41;  friction,  41. 

ICnott,  Van  Buren,  appendectomy,  445. 

Kocher,  death-rate  in  thyroidectomy,  340; 
thyroid  body,  333;  transverse  incision  for 
removal  of  goitre,  337,  338;  operation  for 
removal  of  tongue,  327;  method  of  treating 
dislocation  of  humerus,  187. 

Kolliker,  osteoclasts,  150. 

Krause,  operation  for  excision  of  Gasserian 
ganglion,  247. 

Kredal's  steel  plates  in  brain  surgery,  235. 

Kronlein,  gangrene  of  transverse  colon,  395; 
case  of  appendicitis,  440. 

Labium,  hernia  of,  604. 

Lacerated  wounds,  42;  of  neck,  331;  of  scalp, 
232. 

Lacerations,  of  lobule  of  ear,  283;  of  vagina, 
612;  of  perini-eum,  612;  of  cervix  uteri,  625. 

Lachrymal  gland,  257. 

Lagophthalmos,  252. 

Lamellar  cataract,  267. 

Laminectomy,  166. 

Lange,  treatment  of  oesophageal  strictures,  354. 

Langenbeck's  incision  in  exsectiou  of  the  wrist, 
226. 

Lannelongue,  operation  for  microcephalus,  232. 

Lanphear,  hip-joint  amputation,  83. 

Laplace,  Ernest,  avulsion  for  trifacial  neuralgia, 
247;  skin-grafting,  777. 

Laryngeal  tube,  343. 

Laryngectomy,  complete,  345;  partial,  346. 

Laryngotomy,  342. 

Laryngo-tracheotomy,  342. 

Larynx,  341;  neoplasms  of,  removal  of,  346 
foreign  bodies  in,  343,  767;  fracture  of,  153 

Lateral  ventricle,  aspiration  of,  243,  244 
curvature  of  the  spine,  638;  intestinal 
anastomosis,  427. 

Lawrence's,    strabismometer,  272. 

Le  Conte,  paracentesis  of  pericardium,  369. 

Lee,  amputation  of  leg,  71. 

Leg,  amputation  of,  7();  artificial,  time  to  wear, 
71;  bandage  for,  33;  fracture  of,  178;  vari- 
cose veins  of,  90,  91. 

Lembert,  suture  in  closing  perforations  of 
bowels,  376;  method  of  suturing  veins,  110. 

Lenormant,  cardiac  suture,  368. 

Leprosy,  757. 

Lesions,  of  external  auditory  meatus,  285;  of 
the  palm,  686;  of  the  fingers,  687. 

Leucocytes,  787. 

Leucocytosis,  787. 

Leucoma,  263. 

Leukojmia,  789. 

Levis'  operation  for  hydrocele,  591. 

Levy  and  Baudouin,  injection  of  trifacial  nerve, 
245. 

Lewis'  method  of  treatment  for  double  penis, 
516. 

Ligamentum  teres,  rupture  of,  in  hip  disloca- 
tion, 194;  patellte,  rupture  of,  228. 

Ligation,  of  arteries;  of  innominate  artery, 
113,  114;  of  common  carotid  arteries,  114;  of 
carotid  at  root  of  neck,  118;  of  internal 
carotid  artery,  120;  of  external  carotid,  121, 
122;  of  lingual,  123;  of  facial,  125;  of  ascend- 
ing pharyngeal,  126;  of  internal  mammary, 
131;  of  occipital,  126;  of  posterior  auricular, 
126;  of  femoral,  139;  of  profunda  femoris, 
141 ;  of  popliteal,  141,  142;  of  posterior  tibial, 
141,  142;of  subclavian,  130, 131;  of  vertebral, 
131;  of  axillary  artery,  132;  of  brachial,  133; 


of  radial,  133,  134;  of  ulnar,  1.33,  134;  of 
intercostals,  136;  of  abdominal  aorta,  136, 
137;  of  common  iliac,  138;  of  internal  iliac, 
138;  of  external  iliac,  138;  of  gluteal,  138;  of 
sciatic,  138;  of  internal  pudic,  139;  of  anterior 
tibial,  143;  of  dorsalis  pedis,  143;  of  temporal, 
126;  of  internal  maxillary,  126;  of  superior 
thyroid,  123;  for  occlusion  of  arteries  and 
veins,  110;  in  continuity,  112;  of  extremities 
in  ha?morrhage  from  nose,  294. 

Ligature.  4;  in  haemorrhage,  40,  41;  forceps  for, 
42 ;  aneurism  needle,  42. 

Light  for  ear  examination,  284. 

Linen  for  lateral  ligature,  5,  41,  110. 

Lingual  artery,  ligation  of,  123. 

Lipoma,  of  heart,  369;  of  lips,  304;  of  tongue, 
326,  714;  of  scalp,  229. 

Lips,  angeioma,  moles,  papilloma,  lipoma, 
adenoma  and  fibroma,  ,304;  fissures  and 
phlegmon ,  .304 ;  lupus  of,  303 ;  hypertrophy  of, 
304;  hair  on,  304;  reparative  surgery  of,  304; 
diseases  of,  302. 

Lisfranc,  amputation  at  tarsus,  65. 

Liston's  method  of  reducing  dislocation  at 
elbow,  192. 

Lithiasis,  conjunctival,  261. 

Lithotomy,  540 ;  perineal,  543. 

Lithotrity,  537-40. 

Little  finger,  amputation  of,  54;  disarticulation 
of,  at  carpo-metacarpal  joint,  54. 

Little's  lithotomy  staff,  543. 

Liver,  400 ;  neoplasms  of,  400 ;  carcinoma,  400 ; 
sarcoma,  401;  cysts  of,  401;  abscess  of, 
401;  displacement  of,  402;  wounds  of,  402; 
gunshot  woimds  of,  47. 

Lobule  of  ear,  lacerations  of,  283. 

Local  anassthesia,  18;  cocaine  in,  25;  quinia  and 
urea  in,  27;  in  alcoholics,  16;  in  herniotomy, 
465,  797. 

Local  death  of  bone,  144. 

Lockjaw,  748. 

Long,  J.  W.,  case  of  typhoid  ulcer,  42S. 

Lorenz,  operation  for  congenital  dislocation  of 
hip,  656. 

Lower,  jaw,  fracture  of,  153;  lip,  305;  extremity, 
deformities  of,  686. 

Luckett,  W.  H.,  paraffin,  299. 

Ludwig's  angina,  332. 

Lumbar  hernia,  456,  474. 

Lungs,  malignant  neoplasms  of,  367;  surgery  of, 
365. 

Lupus  of  lips,  303;  nose  and  cheeks,  303; 
vulgaris,  .303;  diagnosis  of,  304;  of  scalp,  230; 
of  conjunctiva,  260. 

Lusk,  Z.  J.,  skin-grafting,  779. 

Ijuxations  {vide  Dislocations),  185. 

Lyraphadenoma,  704,  717. 

Lymphangeioma,  717. 

Lymphangitis,  acute,  84;  symptoms  of,  84; 
treatment  of,  84,  85. 

Lymphatic  glands,  85,  767;  vessels,  84;  in- 
fection of,  84;  varicosities  in,  85;  cystic 
dilatation  in,  85. 

Lymphoma,  of  tonsils,  329 ;  of  neck,  332. 

MacCallum,  W.  G.,  exophthalmic  goitre,  336; 

examination  of  parathyroids,  334. 
Macewen's  operation,  for  genu  valgum,  663; 

for  hernia,  462. 
Mackenzie,  tonsillotome,  329. 
Macnamara,  drilling  in  morbus  coxae,  212. 
Macula,  263. 

Malar  bones,  fracture  of,  152. 
Malformations,  congenital,  of  urethra,  577. 


INDEX 


Malgaigne,  disarticulation   at  calcaneo-astrag- 

aloid  joint,  67. 
Malignant     tumors,     differentiation     between 

benign  and,  719,  720;  oedema,  754. 
Mallet,  10. 

Malposition  of  the  testicle,  600. 
Mammary  gland,  356;  congenital  defects  of, 
356;  abscess  of,  357;  hypertrophy  of,  357; 
tumors  of,  357 ;  adenoma  of ,  357 ;  myxoma  of, 
358;  fibroma  of,  358;  ench'ondroma  of,  358; 
cysts  of,  359;  tuberculosis  of,  359;  sarcoma 
of,  359;  carcinoma  of,  3.59;  encephaloid 
cancer,  360 ;  epithelioma  of,  360 ;  removal  of, 
361;  bandage  for,  35. 
Mammary  artery,   internal,   ligation  of,    131; 

aneurism  of,  106. 
Mandelbaum,    F.    S.,    classification    of    new 

growths  of  the  bladder,  526. 
Marion  Sims,  H.,  treatment  of  incontinence  of 

urine,  525. 
Marsden's  paste,  in  epithelioma  of  ear,  283;  in 
epithelioma  of  nose,  296;  in  epithelioma  of 
nipple,  356;  in  epithelioma  of  eyelids,  251. 
Martin's  rubber  bandage,  29;  for  varicose  veins, 

91;  chair,  431. 
Masland's  saw  in  trephining,  235,  236. 
Mason,  Lewis  D.,  fracture  of  nasal  bones,  152. 
Massage  of  heart,  22. 
Mastitis,  356. 

Mastoid  cells,  291;  bone,  infection  of,  291. 
Matas',  Rudolph,  method  of  treating  aneurism, 
108;  endo-aneurismorraphy,  97;  fracture  of 
zygoma,  treatment,  152. 
Mathews,  neoplasms  of  rectum  and  anus,  487; 

villous  papilloma,  492. 
Mattress  suture,  43. 
Maxilla,  superior,  309. 

Maxillary  artery,  internal,  ligation  of,  126. 
Maydl,  treatment  of  oesophageal  stricture,  354. 
Mayo,  C.  H.  and  W.  J.,  487;  case  of  lateral 
intestinal  anastomosis,  427;  case  of  lateral 
anastomosis,   421;  case  of  carcinoma,   431; 
case  of  urethra,'  578;  case  of  gall  ducts,  411 ; 
operation   for   umbilical   hernia,    472,    473; 
gastro-jejunostomy,  383;  vein  enucleator,  91; 
method    of    removing    veins,    91,    92;    gas- 
trectomy, 393 ;  line,  382 ;  suture  in  gastrect- 
omy,   396;     catgut    suture    in    excision    of 
stomach  ulcers,  382. 
Mayo-Cushing  suture  in  gastrectomy,  379,  382, 

384,  396,  424. 
McBurnej^  Charles,  operation  for  fracture  of 
neck  of  humerus,  177;  method  of  hip-joint 
amputation,   83;  operation   for  fracture   of 
neck  of  humerus,   190;  abdominal  incision, 
372;    gall    ducts,    411;    appendicitis,    440; 
abdominal  section  for  intestinal  occlusion, 
419. 
Measures,  791. 
Meatotomy,  566. 
Median  nerve,  injury  to,  in  dislocation  at  elbow, 

192;  basilic  vein,  45. 
Meibomian  glands,  obstruction  of  ducts  of,  251. 
Membrana  tympani,  wounds  of,  286;  flaccida, 

285. 
Meninges,  carcinoma  of,  231;  sarcoma  of,  231. 
Meningocele,  231. 
Mental  foramen,  314. 
Mercuric  chloride  in  osteomyelitis,  145. 
Mercury,  bichloride  of,  in  major  injuries,  38, 

39;  in  treatment  of  aneurism,  95. 
Mesarteritis,  87. 

Mesentery,  413;  strangulation  through  slits  in, 
417. 


Meso-phlebitis,  86. 

Metacarpo-phalangeal  joints,  exsection  of,  227. 

Metacarpus,  fracture  oif,  165. 

Metastases  with  septicjemia,  742. 

Metatarsal  bones,  fracture  of,  181;  dislocation 

of,  201. 
Metatarsus,  synovitis  in  joints  of,  216. 
Metric  system,  793,  794. 
Meyer,  Willy,  hernia  of  stomach,  391;  costo- 

plastic  operation,  380. 
Michel,  metallic  clamps,  5;  metal  clips,  44. 
Microcephalus,  232. 
Micropsia,  271. 
Milk,    for   colon  alimentation,    349;    quantity 

given,  350. 
Mitchell,    A.    B.,    method    of    treatment    of 

hfemorrhoids,  499. 

Mobilization  of  lesser  curvature  of  stomach,  394. 

Modified,  circular  flaps,  50;  in  amputation  of 

leg.  70;  internal  urethrotomy,  569;  external 

urethrotomy,  570. 

Moles,  90;  dangers  of,  90;  treatment  of,  90;  of 

hps,  304. 
Mollifies  ossium,  145. 
Monks,  G.  H.,  abdominal  section  for  intestinal 

occlusion,  419. 
Moore,  dressing  for  fracture  of  clavicle,  155. 
Morbus  coxa?,  203. 
Morphia,   before    antesthesia,  20,    22,    25;    in 

laryngectomy,  346. 
Morgagni,  cataract,  267. 
Morris,  stab  wound  of  heart,  368. 
Morrow,  P.  A.,  skin-grafting,  779. 
Morton,  T.  G.,  case  of  appendicitis,  440. 
Moschcowitz,  A.  V.,  preparation  of  catgut,  4, 

5;  method  for  cure  of  femoral  hernia,  469. 
Mouth,  contusion  of,  306;  disease  of,  755,  767. 
Mouth-gag,  19. 
Movable  kidney,  506,  507. 
Mucocele,  257. 
Mucous  cysts,  714. 
Multilocular  cysts  of  scalp,  229. 
Mumps,  309. 

Murphy,  J.  B.,  oblong  button  and  key,  389; 
button  forceps,  389 ;  gastro-enterostomy,  389 ; 
button,  377;  anastomosis  of  facial  and  spinal 
accessory  nerves,  249;  operation  for  resection 
of  rectum  in  women,  490,  491;  case  of  puer- 
peral sepsis,  608;  case  of  gall  ducts,  410; 
button,  421, 425,  426;  suppurative  peritonitis, 
451;  fracture  of  olecranon,  162;  adhesions 
between  pericardium  and  pleura,  369; 
pleural  empyema,  366 ;  button  in  gastrectomy, 
396. 
Muscle  volitantes,  271. 

Muscles,  diseases  of,  227,  696;  repair  of,  726. 
Muscular  rheumatism,  of  shoulder-joint,   216; 

of  hip,  205.  , 

Musculo-spiral  nerve,  injury  to,  in  dislocation 
at  elbow,  192;   injury  to,  in  fracture  of  hu- 
merus, 158. 
Mydriatics,  275. 
Myoma  of  the  uterus,  628,  715. 
Myopia,  273,  275. 
Myositis,  638. 
Myringotomy,  289. 
Myxoma,  of   mammary   gland,    358,    715;    of 

nose,  295. 
Myxomata,  of  parotid  gland,  308;  of  antrum  of 
Highmore,  310. 

Najvi  of  scalp,  229. 

Naevus  pigmentosus,  90 ;  treatment  of,  90. 

Nail,  ingrowing,  679,  680. 


810 


INDEX 


Narcosis,  chloroform,  22,  23;  ether,  18-22; 
morphia  in,  20,  22;  nitrous  oxide,  23-25; 
whisky  in,  19,  22. 

Nasal,  bones,  fracture  of,  152;  calcuU,  295;  pm, 
296. 

Nasopharyngeal  catarrh,  298. 

Nachet,  trial  glasses  for  testing  vision,  276. 

Nebula,  263. 

Neck,  abscess  of,  331 ;  Billroth's  disease  of,  333 
brachial  cysts  of,  333;  cystic  tumors  of,  333 
gunshot  wounds  of,  331;  phlegmon  of,  332 
tubercular  lymphoma  of,  332;  tumors  of,  332 
wounds  of,  331. 

Necrosis,  in  adenitis,  85;  of  palate,  317. 

Needle-holder,  12. 

Nelaton's,  test  in  fracture  at  neck  of  femur,  169. 

Neoplasms,  of  thyroid  body,  335;  of  pharynx, 
347;  of  larynx,  346;  avulsion  of,  347;  of 
trachea,  346 ;  of  liver,  400 ;  of  the  rectum  and 
anus,  486;  of  the  bladder,  526;  of  the  urethra 
580;  of  the  vagina,  623;  of  the  spine,  694 
to  classification  of,  698;  non-malignant,  712 
of  bladder,  400 ;  of  the  intestines,  418;  benign, 
of  auricle  of  ear,  283;  of  nose,  295. 

Nephrectomy,  508. 

Nephrolithiasis,  505. 

Nerves,  695;  inferior  dental,  exsection  of,  314; 
repair  of,  727;  stretching  of,  696;  suture  of, 
696. 

Nervous  sj'stem,  765. 

Nettleship,  trachoma,  259;  pannus,  262. 

Neuralgia,  from  aneurism,  94;  of  prostate,  558; 
of  rectum,  493;  trifacial,  245;  of  shoulder- 
joint,  216;  of  hip-joint,  206. 

Neuritis,  optic,  271,  281. 

Neuroma,  716. 

New  growths,  classification  of,  698. 

Niles,  H.  D.,  ulcer  of  sigmoid,  430. 

Nipple,  angeioma  of,  356;  cysts  of,  356;  eczema 
or  fissure  of,  356;  epithelioma  of,  356;  inflam- 
mation of,  356;  papilloma  of,  356;  fibroma 
of,  356. 

Nitrate  of  silver,  in  neoplasms  of  larynx,  347; 
in  ulcers  of  tongue,  326. 

Nitric  acid,  in  gonorrhceal  ophthalmia,  259;  in 
phlyctenular  keratitis,  263;  in  polyp  of  nose, 
295. 

'Nitrous  oxide,  23;  with  oxygen,  17-25;  with 
morphia,  25;  with  ether,  24,  25;  in  extraction 
of  teeth,  315;  sequestration  in,  17;  mortality, 
17;  administration  of,  24;  duration  of,  23;  in 
fracture  at  elbow,  161 ;  in  removal  of  varicose 
veins,  91. 

Non-malignant  neoplasms,  712. 

Non-specific,  urethritis,  563,  762;  ulcers,  585. 

Nose,  294;  adenoid  vegetations  in,  298; 
angrdar  depressions  of,  298 ;  congenital  lesions 
of,  301;  fibromata  of,  295;  fissures  of  nares, 
295;  foreign  bodies  in,  294 ;  haemorrhage  from, 
294;  loss  of  substance  of,  299;  lupus  of,  303, 
767;  neoplasms,  295;  rhinitis,  295;  tampon  of, 
294. 
Nostrils,  papillomata  of,  295. 
Nuclear  cataract,  266. 

Nyctalopia,  271. 

Obstruction  of  the  intestines,  414. 

Obturator  hernia,  456,  474. 

Occipital  artery,  hgation  of,  126. 

Occlusion  of  arteries  and  veins,  110;  intestinal, 

419. 
Ochsner,  A.  J.,  case  of  appendicitis,  446,  447. 
O'Dwyer,  laryngeal  tube,  343. 
CEdema  of  scrotum,  588;  malignant,  754. 


CEsophagectomy,  352. 

CEsophagotome,  Sands,  351. 

CEsophagotomy,  internal,  351;  for  removal  of 
foreign  bodies,  348. 

(Esophagus,  rupture  of,  347;  foreign  bodies  in, 
347;  sound,  347;  stricture  of,  350;  new 
formations  in,  354;  fistula  of,  352,  767. 

Oiled  silk,  13. 

Oleate  of  mercury  in  lupus,  303. 

Olecranon,  fracture  of,  161. 

Omentum,  413;  strangulation  through  slits  in, 
417. 

Opacity,  of  lens,  266;  of  cornea,  263. 

Operating  room,  7,  8;  table,  6,  8. 

Operation  on  mastoid  bone,  291;  for  sinus 
thrombosis,  292;  for  relief  of  ascites,  402,  403. 

Operative  arteriorrhaphy,  98. 

Ophthalmia,  gonorrhceal,  259,  562. 

Ophthalmic  artery,  aneurism  of,  104. 

Ophthalmitis,  sympathetic,  265. 

Ophthalmoscope,  in  cataract,  267;  in  choroiditis, 
264. 

Ophthalmoscopy,  280. 

Optic  nerve,  atrophy  of,  281;  neuritis  of,  271, 
281. 

Oral  screw,  19. 

Orbicularis  palpebrarum  muscle,  spasm  of, 
252. 

Orchitis,  562;  testicle,  enlargement  of,  562,  596; 
in  mumps,  309. 

Organs,  genito-urinary,  in  females,  602. 

Ormsby  inhaler,  19. 

Os  innominatum,  fracture  of,  167;  hyoides, 
fracture  of,  154;  calcis,  fracture  of,  181. 

Osteo-arthritis,  of  ankle-joint,  216;  of  knee- 
joint,  213;  of  joints,  202. 

Osteoma,  718;  of  skull,  231. 

Osteomalacia,  145;  in  ununited  fractures,  181. 

Osteomyelitis,  acute,  144;  tuberculous,  145. 

Osteotome,  10. 

Osteotomy  at  the  hip,  658. 

Ostitis,  in  ununited  fractures,  182;  varieties 
of,  144;  tuberculous,  145;  deformans,  146; 
interna  caseosa,  145 ;  of  hip,  205,  206 ;  of  skull, 
230;  periostitis  of  ribs  as  cause  of  sub- 
axillary  abscess,  357;  of  upper  jaw,  309;  of 
lower  jaw,  312. 

Otis,  F.  N.,  dilating  urethrotome,  567. 

Otitis  media,  290. 

Ovariotomy,  631. 

Ovaritis,  611. 

Ovary,  hernia  of,  604;  tumors  of,  631,  636; 
cysts  of,  636;  dermoid  cysts,  636. 

Ozffina,  295. 

Pagenstecher,  celluloid  linen,  388. 

Palate,  affections  of,  317;  cleft  of,  317;  opera- 
tion for  cleft  of,  318. 

Pallida,  spirochaete,  790. 

Palm,  fascia  of,  686;  lesions  of,  686. 

Pancreas,  412;  tuberculosis  of,  413;  calculus  of, 
413. 

Pannus,  261. 

Panopeptone  for  colon  alimentation,  350. 

Papilloma,  of  tongue,  326;  of  lips,  304;  of 
lai-ynx,  329;  of  rectum,  492,  712;  of  antrum 
of  Highmore,  310. 

Papillomata,  of  nostrils,  295;  of  scalp,  229;  of 
larynx,  346. 

Paraffin,  Luckett,  299. 

Paralysis,  from  fracture  of  humerus,  147;  of 
deltoid,  681;  facial,  249. 

Paraphimosis,  762. 

Parasites  in  the  urine,  533. 


811 


Parathyroid  bodies,  334;  acute  tetany  from 
removal  of,  334. 

Paronychia,  688. 

Parotid  gland,  removal  of,  307,  308;  tumors  of, 
306,  308;  duct,  306. 

Parotitis,  309. 

Parovarium,  tumors  of,  636. 

Parrish,  B.  F.,  muscle  tendon  grafting,  228. 

Partial  larjmgectomy,  346;  rhinoplasty,  .301. 

Patella,  rupture  of  ligament  of,  228;  dislocation 
of,  200;  fracture  of,  17-5;  removal  of,  in  knee- 
joint  amputation,  73,  74. 

Pathological  dislocation,  185;  at  hip,  195;  at 
knee-joint,  199. 

Pathology  of  syphilis,  768. 

Patient,  examination  of,  2  ;  preparation  of, 
1,2. 

Pawlik's  method  of  urethral  catheterization, 
513,  514. 

Pelvis,  dislocation  of,  201. 

Penetrating  wounds,  of  abdomen,  375;  of  skull 
and  brain,  232. 

Penis,  double,  515,  516;  wounds  of,  580; 
Humphrey's  operation  for  amputation  of, 
582;  carcinoma  of,  581 ;  herpes  of,  585;  phage- 
denic ulcer  of,  586,  587;  sarcoma  of,  583; 
ulcer  of,  585. 

Peptonized,  milk,  for  colon  alimentation,  349, 
350;  for  food,  349,  350. 

Perforation  of  stomach,  399. 

Periarteritis,  87;  phlebitis,  86. 

Periarticular  inflammation  of  hip,  205. 

Pericardium,  adhesions  of,  369;  dropsy  of,  369. 

Perichondroma,  717. 

Perineal,  lithotomy,  543;  hernia,  458;  pros- 
tatectomy. Young's  operation  for,  550-553. 

Perinajum,  laceration  of,  612;  rupture  of  and 
operation  for,  613,  623. 

Periosteotomes,  Brophy,  320. 

Periosteum,  728;  process  of  repair,  in,  728. 

Periostitis,  serous,  144;  non-suppurative  or 
fibrous,  144;  acute,  144;  tuberculous,  144;  of 
jaw,  309;  of  skull,  230. 

Peritonitis,  from  perforation  of  stomach,  399; 
general  suppurative,  449;  tuberculous,  451. 

Petit's  fracture  box,  180. 

Phagedenic  ulcer  of  penis,  586,  5S7. 

Phalangeal  joints,  disarticulation  of,  52,  53. 

Phalanges,  of  toes,  dislocation  of,  20 1 ;  of  fingers, 
dislocation  of,  193;  reduction  of,  194,  195; 
of  hand,  fracture  of,  165;  of  foot,  fracture  of, 
181. 

Pharyngotomy  in  neoplasms  of  larvnx,  341, 
347. 

Pharynx,  neoplasms  of,  347;  foreign  bodies  in, 
347. 

Phimosis,  584,  585,  762. 

Phlebitis,  86;  symptoms  of,  87;  treatment  of, 
87;  dangers  of,  87. 

Phlegmon,  of  lips,  304;  of  neck,  332;  of  hands, 
689;  of  fingers,  689. 

Phlyctenulse,  of  conjunctiva,  262;  of  cornea, 
262. 

Pilcher,  L.  S.,  method  of  treatment  of  hasmor- 
rhoids,  498,  499;  method  of  reducing  CoUes' 
fracture,  165. 

Pinguecula,  260. 

Pityriasis  versicolor,  of  rectum  and  anus,  478. 

Planus,  talipes,  676. 

Plaster-of-Paris  bandage,  in  fracture  of  hume- 
rus, 156 ;  in  CoUes'  fracture,  165 ;  in  fracture  of 
acromion  process,  155;  in  fracture  of  patella, 
176;  in  fracture  of  thigh,  173;  in  fracture  of 
leg,  179;  in  ununited  fractures,  182;  in  treat- 


ment of  fractures,  148;  in  Pott's  fracture,  180 ; 
Sayre's,  for  Pott's  disease,  649;  bandage,  29; 
bandage  in  sprains,  202;  in  liip  disease.  210. 

Pleura,  surgery  of,  365. 

Pleuritis,  365. 

Plugging  of  nares,  294. 

Pneumonectomy,  366. 

Pneumonia  from  foreign  bodies  in  air  passages, 
344. 

Pneumo-thorax,  365. 

Pneumonotomy,  366. 

Pneumorrhaphy,  366. 

Politzer's  perforator,  285;  inflation  of  tym- 
panum, 286,  288. 

Polydaotylus,  676,  685. 

Polypoid  growths  of  heart,  369. 

Polypus,  of  conjunctiva,  260;  of  rectum,  491. 
492;  of  nose,  295. 

Poole,  E.  H.,  parathyroids,  334. 

Popliteal  artery,  aneurism  of,  93,  108;  ligation 
of,  141,  142. 

Porter,  M.  F.,  cysts  of  mesentery,  413. 

Port-wine  marks  of  scalp,  229. 

Position,  Sims',  602. 

Posterior  tibial  artery,  ligation  of,  142 ;  auricular 
artery,  ligation  of,  126;  curvature  of  the 
spine,  644,  645;  synechia,  264. 

Posthitis,  560,  762. 

Potassium  permanganate  in  snake  bite,  46. 

Pott's  disease  of  the  spine,  645;  suspension  ap- 
paratus for  applying  Sayre's  plaster-of -Paris 
jacket,  145,  649;  fracture,  178,  179. 

Pregnancy,  hysterectomy  during,  633. 

Preparation  of  patient  for  operation,  1,  2. 

Presbyopia,  278. 

Primitive  dislocation,  185. 

Prince's  forceps,  259. 

Probes,  12. 

Process  of  repair,  in  the  periosteum,  728;  in 
bone,  728. 

Proctitis,  gonorrhoeal,  562. 

Profunda  femoris  artery,  ligation  of,  141. 

Prolapse  of  the  rectum,  493. 

Prostate,  547;  carcinoma  of,  557;  tuberculosis 
of,  557;  neuralgia  of,  558;  treatment  for 
hypertrophy  of,  549,  550. 

Prostatectomy,  5-50,  551;  perineal.  Young's 
operation  for,  550-553. 

Prostatic  hypertrophy,  changes  in  contour  of, 
.554,  555;  sarcoma,  557;  concretions,  557. 

Prostatorrhoea.,  555. 

Pruritus,  ani,  478-501;  vulva;,  604. 

Pryor,  W.  R.,  operation  for  puerperal  septi- 
caemia, 609;  lock  forceps,  635;  operation  for 
vaginal  hysterectomy,  635. 

Pterygium,  260. 

Ptosis,  252. 

Pudendal  hernia,  458,  474. 

Puerperal  endometritis,  608;  septicaemia, 
Prj'or's  operation  for,  608,  609. 

Pulmonary  gangrene,  366. 

Punctured  wound,  42;  wounds  of  neck,  331. 

Pus  in  blood,  531,  737. 

Pyelitis,  .503,  504. 

Pyelonephritis,  503,  504. 

Pysemia,  742. 

Pyrogallic  acid  in  lupus  vulgaris,  304. 

Quadriceps  extensor  muscle,  rupture  of,  227. 
Quenu's    operation    for    resection    of    rectum, 

Tuttle's  modification  of,  487-489. 
QuiU  suture,  43. 
Quinia  and  urea  hydrochloride,  797;  Thibault, 

27;    preparation,    27;    ingredients,    28;    for 


812 


INDEX 


curetting   ulcers,  28;   mucous   surfaces,  28, 
797. 
Quinine  in  tonsillitis,  329. 

Rabies,  751. 

Rachitis.  146,  182. 

Radial  arterj',  ligation  of,  13.3.  134;  aneurism 
of,  106. 

Radius,  dislocation  of  head  of,  191;  reduction 
of,  191;  dislocation  of  radius  and  ulna,  191- 
193;  fracture  of,  163;  of  shaft,  164;  Colles' 
fracture  of,  164. 

Ramus  of  jaw,  fracture  of,  153. 

Ranula,  328. 

Rassieur,  Lewis,  excision  of  a  portion  of  the 
lung,  366. 

Rattle-snake,  4.5. 

Razors,  13. 

Recent  dislocation,  185. 

Reconstructive  arterioplasty,  97,  98. 

Rectal  ana?sthesia,  28. 

Recto-vaginal  septum,  613;  rupture  of,  613. 

Rectum,  absence  of,  476;  foreign  bodies  in,  479; 
erythema  of,  478;  stricture  of.  484,  485; 
neoplasms  of,  486;  herpes  of,  478;  pityriasis 
versicolor,  478;  atresia  of,  477;  eczema  of, 
478;  ulcers  of,  482;  syphilitic  chancre  of, 
483,  484;  resection  of  431^33,  487;  polypus, 
491,  492;  papilloma  of,  492;  prolapse  of,  493; 
neuralgia  of,  493;  catarrhal  inflammation  of, 
500;  tuberculosis  of,  500;  gonorrhoeal  in- 
fection of,  500. 

Reef  knot,  41;  in  tj'ing  arteries.  111. 

Reeves,  operation  on  the  ear,  2S_3. 

Refraction  of  eye,  273. 

Relaxation  of  vulvo-vaginal  outlet,  617;  opera- 
tion for,  618-621. 

Repair,  of  skin,  726;of  muscles,  726;  of  tendons, 
726;  of  nerves,  727;  in  bone,  728;  in  peri- 
osteum, 728;  of  cartilage,  731. 

Reparative  surgery  on  the  hps,  304. 

Resection,  of  the  rectum,  431-433,  487;  Mur- 
phy's operation  for  (in  women),  490,  491 ;  of 
the  intestines,  421-424;  of  inferior  dental 
nerve,  114. 

Retention  of  urine,  561. 

Restoration  of  eyelids,  256. 

Retina,  271. 

Retinitis,  281;  pigmentosa,  271. 

Retractors,  10;  silk  or  linen,  370. 

Retropharyngeal  abscess,  331;  diagnosis  of, 
332,  647. 

Retroversion  of  the  uterus,  612. 

Reversed  Trendelenburg  posture  in  removal  of 
thyroid  body,  334;  in  removal  of  parotid 
gland,  308. 

Review  of  fractures  about  elbow,  161. 

Rheumatism,  as  cause  of  strabismus,  273; 
gonorrhoeal,  562. 

Rhinitis,  hyi^ertrophic,  296;  atrophic,  297. 

Rhinolites,  295. 

Rhinoplasty,  from  forehead,  300;  partial,  301. 

Riberi,  operation  of  Steno's  duct,  307. 

Ribs,  fracture  of,  166;  dislocation  of,  201. 

Rickets  in  ununited  fractures,  146,  182. 

Ricketts,  pneumorrhaphy,  366;  suture  of  heart, 
366. 

Ring-finger,  amputation  of,  54. 

Roberts,  John  B.,  deflected  septum,  296;  nasal 
pin,  296. 

Robin  myeloplaxes,  149,  150. 

Robinson,  A.  R.,  lupus,  303;  carbuncle,  779. 
Rockey,  valvular  method  of  closing  gall  bladder, 
404. 


Rodman,  W.  L.,  resection  of  stomach,  383. 

Roentgen  ray,  in  fracture  of  humerus,  156, 157; 
in  fracture  about  elbow,  158;  in  fractures, 
147,  148;  in  dislocations,  185. 

Rogers,  serum  in  goitre,  340. 

Rokitansky,  diverticula  of  oesophagus,  352. 

Roller  for  bandage,  29. 

Rongeur  forceps,  11. 

Roosevelt's  clamp,  427. 

Rotary-lateral  curvature  of  the  spine,  638,  641. 

Round-cell  sarcoma,  706. 

Royster,  H.  A.,  case  of  appendicitis,  441. 

Rubber,  tubing,  in  hip-joint  amputation,  77; 
tissue,  13,  14;  gloves,  3. 

Rupture,  of  the  bladder,  517;  of  the  recto- 
vaginal septum,  613;  of  the  perinseum,  613; 
of  oesophagus,  347. 

Russell,  R.  Hamilton,  hypospadias,  577. 

Sacculated  aneurism,  99. 

Sacrum,  fracture  of,  167. 

Saline  solution,  for  intravenous  injection,  45;  in 
major  injuries,  48. 

Salivary  fistula,  306. 

Salpingitis,  610. 

Salt  solution  for  intravenous  infusion,  45. 

Sands,  cesophagotome,  351. 

Sarcoma,  of  oesophagus,  354;  of  upper  and 
lower  jaw,  prognosis  of,  313;  of  thyroid  body, 
335;  of  heart,  369;  of  mammary  gland,  359; 
of  lung,  367;  of  stomach,  398;  of  dura  mater, 
231;  of  parotid  gland,  308;  of  tonsils,  329; 
toxines  for,  309;  of  antrum  of  Highmore,  310; 
prostatic,  557;  of  the  penis,  583;  of  the 
testicle,  599;  of  the  uterus,  630,  705;  round- 
cell,  706;  spindle-cell,  706;  giant-cell,  707; 
treatment  of,  710,  711;  of  the  liver,  401. 

Saw,  10;  electric,  in  trephining,  235,  236. 

Sayre,  exsectionof  hip-joint,  217;  apparatus  for 
fractured  clavicle,  186;  elevator  in  exsection 
of  ankle-joint,  221;  wire  breeches,  211; 
muscular  torticollis,  639;  dressing  for  frac- 
tured clavicle,  155;  periosteal  knife,  11; 
elevator,  19;  suspension  apparatus  for  ap- 
plying plaster-of-Paris  jacket  for  Pott's 
disease,  649. 

Scalds,  774. 

Scale,  United  States,  571. 

Scalp,  lipomata  of,  229;  nsevi  of,  229;  papillo- 
mata  of,  229;  ulcers  of,  230;  tuberculosis  of, 
230;  elephantiasis  of,  230 ;  hsBmatoma  of ,  230; 
abscess  of,  230;  pneumatocele  of,  230; 
tumors  of,  229;  cysts  of,  229;  dermoids  of, 
229;  sebaceous  cyst,  229;  horns  of,  229; 
wounds  of,  232. 

Scalpels  for  eyelid,  255. 

Scapula,  fracture  of,  155. 

Schaede's  operation  for  varicose  veins,  92. 

Sciatic  artery,  ligation  of,  138;  aneurism  of,  107. 

Scirrhus  carcinoma  of  heart,  359. 

Scissors  for  iris,  12,  266. 

Scleritis,  264. 

Sclerotic,  264. 

Scoliosis,  638. 

Scorpion,  46. 

Scrotum,  wounds  of,  588;  cedema  of,  588; 
eczema  of,  588;  cysts  of,  588;  erysipelas  of, 
588;  elephantiasis  of,  588;  angeioma  of,  588; 
epithelioma  of,  589;  fistulas  of,  589;  hsema- 
toma  of,  589. 

Scudder,  stomach  clamp,  396. 

Sebaceous  cysts  of  scalp,  229. 

Sebanijew,  gastrostomy,  352. 

Secondary  dislocation,  185. 


813 


Sedillot,  amputation  of  leg,  71. 

Seminal  vesicles,  558. 

Senile  cataract,  267;  gangrene,  783. 

Senn,  abdominal  section  for  intestinal  occlusion, 
419. 

Separation  of  the  pyloric  end  of  the  stomach, 
394. 

SepticEemia,  puerperal,  Pryor's  operation  for, 
608,  609,  741 ;  with  metastases,  742. 

Sequestration,  Dawbarn,  in  formidable  opera- 
tions about  mouth,  314;  in  removal  of  thyroid 
body,  334;  in  removal  of  parotid  gland,  308; 
in  removal  of  tongue,  327;  in  removal  of 
goitre,  337;  in  gunshot  wounds  of  skull  and 
brain,  16,  17,  20,  28,  233. 

Sequestrum,  144;  forceps,  12. 

Serous  cysts,  714. 

Sexton's  probe,  284;  ear  forceps,  284;  ear-hook, 
284;  snare,  285. 

Shaffer's  abduction  hip  apparatus,  209;  knee- 
splint,  214;  rotary-lateral  curvature  ap- 
paratus, 644;  head  and  chin  support,  654. 

Shock,  caffeiu  and  camphor  in,  49;  in  amputa- 
tions, 49;  cause  of,  49;  anfesthesia  in,  49; 
syncope  in,  49;  psychical,  49;  haemorrhagic, 
49;  in  brain  surgery,  233;  in  penetrating 
wounds  of  abdomen,  375. 

Shoulder,  ankylosis  of,  681 ;  congenital  dislo- 
cation at,  681. 

Shoulder-joint,  exsection  of,  222 ;  dislocation  of, 
186;  general  considerations,  190;  synovitis  of, 
216;  tuberculous  osteo-arthritis  of,  217. 

Shrapnell's  membrane,  285;  incision  of,  289. 

Sigmoid  colon,  catarrhal  inflammation  of,  500. 

Silk,  41;  retractors,  370;  for  lateral  ligatures, 
110. 

Silkworm  gut,  5,  44. 

Silver  wire,  5. 

Simple,  conjunctivitis,  258;  dislocation,  185; 
goitre,  334. 

Sims,  J.  Marion,  rectal  speculum,  479;  position, 
602;  glass  cylinder  of,  607;  operation  for 
vesioo-vaginal  fistula,  623;  speculum,  625; 
removal  of  lower  jaw,  313. 

Sinus,  thrombosis,  292. 

Skin,  repair  of,  726;  syphilis  of,  765;  grafting, 
775-77;  injury  of,  in  amputations,  48. 

Skull,  ostitis  of,  230;  periostitis  of,  230;  osteoma 
or  exostosis  of,  231;  trephine  of,  234;  pene- 
trating wounds  of,  232;  fractures  of,  150. 

Small  intestine,  lesions  of,  374. 

Smith's  clamp,  499. 

Smith,  Stephen,  amputation  of  leg,  70;  at  knee, 
73,  74. 

Snake-bite,  45;  antidote  for,  46;  bromine, 
iodine,  sodium  and  potassium  hydrate  and 
potassium  permanganate  in,  46;  symptoms, 
46;  duration  of ,  46;  treatment,  46;  toxicity 
of,  45;  prognosis,  45;  tourniquet  in,  46. 

Snap-finger,  687. 

Snellen's  test-types,  277;  operation  for  en- 
tropion, 255. 

Sound  for  oesophagus,  348,  571. 

Spasm,  of  ciliary  muscle,  275;  of  the  vagina, 
606. 

Special  joints,  diseases  of,  203;  dislocations, 
185;  aneurisms,  99. 

Speculum  oris,  19;  Sims'  rectal,  479,  625. 

Spermatic  cord,  transplantation  of,  797. 

Spermatorrhoea,  557. 

Spherical  aneurism,  93. 

Spina  bifida,  694. 

Spinal  accessory  nerve,  anastomosis  with  facial 
nerve,  249;  column,  deformities  of,  638;  cord. 


693;  analgesia,  28;  usage,  28;  Bainbridge's 
method,  28. 

Spindle-cell  sarcoma,  706. 

Spine,  deformities  of,  638;  curvature  of,  638; 
rotary-lateral  curvature  of,  638,  641;  lateral 
curvature  of,  638;  anterior  curvature  of,  644, 
645;  posterior  curvature  of,  644,  645;  Pott's 
disease  of,  645;  Taylor's  brace,  654;  con- 
cussion of,  693;  contusion  of,  693;  penetrat- 
ing wounds  of,  693;  hsemorrhage,  693,  694; 
dislocation  of,  693;  fractures  of,  693;  neo- 
plasms of,  694. 

Spirochsete  pallida,  790. 

Spleen,  411;  abscess  of,  411;  displacement  of, 
412;  cysts  of,  412;  hernia  of,  412;  gunshot 
wounds  of,  47. 

Splenectomy,  412. 

Spondylitis,  645. 

Spoons,  sharp,  11. 

Sprain,  202. 

Stab  wound  of  heart,  368. 

Staff,  Little's  lithotomy,  543. 

Staphyloma  corneae,  263. 

Steno's  duct,  calculi  of,  307. 

Sterilization,  of  patient,  2 ;  of  hands,  3 ;  of  gauze, 
cotton,  towels,  sheets,  etc.,  4;  of  instruments, 
13. 

Sterilizer,  4. 

Sternum,  fracture  of,  165. 

Stevens,  Geo.  T.,  phorometer,  278. 

Stimson,  L.  A.,  method  of  reducing  hip-joint 
dislocation,  197,  198. 

Stings,  of  bees,  46;  of  wasps,  46;  of  hornets,  46. 

Stomach,  379;  hernia  of,  391;  carcinoma  of,  392; 
perforation  of,  399;  sarcoma  of,  398;  foreign 
bodies  in,  379;  wounds  of,  379;  ulcers  of,  381 ; 
hour-glass,  389;  adhesions  of,  390;  mobiliza- 
tion of  the  lesser  curvature  of,  393;  separa- 
tion of  the  pyloric  end  of,  394;  freeing  the 
greater  curvature  of,  395;  removal  of  diseased 
structures  of,  396. 

Stone,  in  bladder,  533 ;  in  kidneys,  505 ;  in  female 
bladder,  545. 

Strabismometer,  272. 

Strabismus,  272;  scissors,  272. 

Strangulated  inguinal  hernia,  464. 

Strangulation  through  slits  in  mesentery,  417; 
in  omentum,  417. 

Stretching  of  nerves,  696. 

Stricture  of  the  rectum,  484^85;  of  the  ureter, 
509;  of  the  male  urethra,  563;  of  the  in- 
testines, 418;  divulsion  of  urethral,  567;  of 
the  vagina,  607;  of  oesophagus,  350;  gas- 
trostomy for,  352. 

Stylet,  Keyes',  524. 

Subacromial  dislocation,  reduction  of,  190. 

Subclavian  artery,  ligation,  130;  anatomy  of, 
127;  aneurism  of,  104,  105. 

Subclavicular,  dislocation,  186,  187. 

Subcoracoid  dislocation,  186,  187. 

Subcutaneous  suture,  44. 

Subcuticular  suture,  44. 

Subglenoid  dislocation,  180,  189,  190. 

Sublimate  for  irrigation  in  exsection  of  hip- 
joint,  218. 

Subluxation  of  head  of  radius,  1 91. 

Submaxillary  gland,  309. 

Subphrenic  abscess,  401,  402. 

Subspinous  dislocation,  187,  190. 

Suction  for  cataract,  270;  for  snake-bites,  46. 

Sugar  in  urine,  530. 

Sulphate  of  copper  in  follicular  conjunctivitis, 
258. 

Sulphide  of  calcium  in  hordeolum,  251. 


814 


INDEX 


Superior  intercostal  artery,  origin  of,  130; 
thyroid  artery,  ligation  of,  123. 

Superior  maxilla,  309;  removal  of,  311 ;  fracture 
of,  152;  vide  jaw. 

Suppression  of  the  urine,  526. 

Suppuration,  in  lymphangitis,  84;  in  adenitis, 
85;  in  tubercular  adenitis,  86,  736. 

Suppurative  peritonitis,  general,  449. 

Suprapubic  cystotomy,  540. 

Supra-scapular  artery,  relations  of,  129. 

Surgery  of  pleura,  365;  of  lungs,  365;  of  bronchi, 
365;  of  heart,  367;  of  bones,  144. 

Surgical,  operation,  1;  dressings,  13;  instru- 
ments, 8,  9,  10,  11,  12;  occlusion  of  arteries 
and  veins,  110;  diseases  of  bones,  144,  721. 

Suspension  apparatus,  for  applying  Sayre's 
plaster-of-Paris  jacket,  649  ;  Meigs  case, 
655. 

Suture,  4;  of  wounds,  43;  alternating  deep  and 
superficial,  43;  interrupted,  43;  continuous, 
43;  mattress,  43;  qUill  or  lead-plate,  43; 
silver-wire,  43 ;  silkworm  gut,  44 ;  subcuticular, 
44;  needles  for,  45;  of  gastric  stump,  396; 
Mayo-Cushing  in  gastrectomy,  379 ;  in  closing 
perforations  of  bowels,  376;  of  arteries,  109- 
111;  of  veins,  109-111;  tendonof  fingers,  687; 
of  nerves,  696. 

Swanzy  conjunctivitis,  258. 

Symblepharon,  253. 

Syme  amputation  at  tibio-tarsal  joint,  68. 

Sympathetic  023htha]mitis,  265. 

Symphyseotomy,  633. 

Synchisis,  270. 

Syncope,  in  shock,  49;  in  ha;morrhage,  45. 

Syndactylus,  676,  685. 

Syndesmitis  of  joints,  202. 

Synechia,- anterior,  263;  posterior,  264. 

Synovitis,  in  articulations  of  tarsus,  216;  of 
metatarsus,  216;  of  laiee-joint,  212;  of  shoul- 
der-joint, 216;  of  joints,  202;  of  ellaow-joint, 
217;  of  wrist-joint,  217;  of  metacarpal  joints, 
217;  of  phalangeal  joints,  217;  of  hii>joint, 
205. 

Synovo-arthritis,  203. 

Syphilis,  758,  762-767;  of  the  skin,  765;  pathol- 
ogy of,  768;  diagnosis  of,  769;  treatment  of, 
771,  772;  inherited,  772;  in  ununited  frac- 
tures, 182. 

Syphilitic,  ostitis,  146;  periostitis,  146;  arteritis, 
766 ;  chancre  of  rectum  and  anus,  483,  484. 

System,  nervous,  765;  metric,  793,  794. 

Table,  operating,  6,  8. 

Talipes,    665;   equinus,    665;   calcaneus,    667; 

varus,  668;  valgus,  673;  cavus,  675;  planus, 

676. 
Tarantula,  46. 
Tarsorrhaphy,  252. 
Tarsotomy',  672. 
Tarsus,  synovitis  in  joints  of,  216;  fractures  of, 

181;  dislocation  of ,  201. 
Taylor's  brace  for  spine,  654. 
Teale,  amputation   of   leg,    71 ;   operation   for 

symblepharon,  253. 
Teeth,  extraction  of,  315. 
Telangiectasis  of  larynx,  346. 
Temporal  artery,  ligation  of,  126. 
Tendo  Achillis,  division  of,  668. 
Tendons,  696;  repair  of,  726;  diseases  of,  227; 

tuberculosis  of,  227. 
Tenotomy,  for  strabismus,  272;  of  internal  rec- 
tus muscle,  272,  691. 
Testicle,  596 ;  tuberculosis  of ,  598 ;  enchondroma 

of,  599'  adenoma  of,  599;  carcinoma,  599; 


sarcoma,  599;  malposition  of,  600,  767; 
atrophy  of,  in  mumps,  309;  abscess  of,  309. 

Testing  vision  for  glasses,  277. 

Test-types,  of  Jaeger,  277;  of  Snellen,  277. 

Tetanus,  748. 

Thecitis  at  ankle-joint,  215. 

Theobold's  lachrymal  probe,  257. 

Thermal  inhaler,  19. 

Thermometric  scales,  796. 

Thibaidt's  method,  quinia  and  urea,  27. 

Thigh,  amputation  through,  75;  bandage  for, 
33. 

Thomas'  method  of  treating  hip  disease,  209; 
hip  splint,  209. 

Thompson,  W.  Oilman,  carcinoma  of  stomach, 
392. 

Thoracic  aorta,  aneurism  of,  99,  102. 

Thread-worms,  479. 

Thrombosis  of  sinus,  292. 

Thumb,  dislocation  of  metacarpal  bone  of,  193; 
amputation  of,  53 ;  disarticulation  of,  53 ; 
metacarpal  joint,  55. 

Thyroid  body,  333;  neoplasms  of,  335;  sarcoma 
of,  335;  carcinoma  of,  335;  functional  dis- 
turbances of,  336;  removal  of,  337;  infection 
of,  334;  cachexia  from  removal  of,  334; 
hypertrophies  of,  334;  hydatid  cysts  of,  341; 
wounds  of,  334;  artery,  ligation  of,  123;  axis, 
relations  of,  129. 

Thyroidectomy,  337. 

Thyrotomy  in  neoplasms  of  larynx,  342,  347. 

Tibia,  fracture  of,  178;  dislocation  of,  199. 

Tibial  arteries,  aneurism  of,  108. 

Tibio-tarsal,  amputation,  68;  preservation  of 
vascular  supply,  68;  dislocation,  200. 

Tiemann,  tonsillotome,  330. 

Tissue,  connective,  726. 

Toad,  46. 

Tobacco  as  cause  of  atrophy  of  optic  nerve,  281. 

Toes,  deformities  of,  676,  677. 

Tongue,  controlling  haemorrhage  of,  325; 
hypertrophy  of,  325;  cystic  tumors  of,  325; 
atrophy  of,  325 ;  angeioma  of ,  325 ;  abscess  of, 
325;  ulcers  of,  326;  epithelioma  of,  326; 
adhesion  of,  328;  bifid,  328;  excision  of,  by 
Gant's  method,  327;  excision  by  Kocher's 
method,  327;  forceps,  19,  767;  removal  of, 
327;  wounds  of,  325;  tie,  328. 

Tonsillitis,  cause  of  adenitis,  85;  acute,  328. 

Tonsillotome  of  Mackenzie,  329;  of  Tiemann, 
330. 

Tonsillotomy,  329. 

Tonsils,  328;  abscess  of,  329;  chronic  hyper- 
trophy of,  329 ;  removal  of,  329 ;  sarcoma  of, 
329 ;  carcinoma  of,  329;  cystic  tumors  of,  329; 
fibroma  of,  329;  lymphoma,  329;  as  factor  in 
tubercular  adenitis,  85. 

Torsion  in  haemorrhage,  40,  41,  110,  111. 

Torticollis,  638. 

Tourniquet  in  snake-bite,  46. 

Toxines,  Coley,  in  sarcoma  of  parotid  gland, 
309. 

Trachea,  341;  canula  for,  342;  neoplasms  of, 
346;  foreign  bodies  in,  343. 

Tracheotomy  for  foreign  bodies,  342,  345;  for 
removal  of  tumors  of  laryiigo-pharynx,  342. 

Trachitis  from  foreign  bodies  in  air  passages, 
344. 

Trachoma,  258. 

Transplantation  of  spermatic  cord,  797. 

Transversalis  coli  artery,  relations  of,  129. 

Traumatic  dislocation,  185;  at  hip,  195;  synovo- 
arthritis,  202;  at  knee,  199;  endarteritis,  41; 
keratitis,  261 ;  mastitis,  356. 


INDEX 


815 


Treatment  of  hj-pertrophy  of  the  prostate, 
549,  550;  of  syphilis,  771.  772. 

Trephine,  electric,  236;  Gait,  151,  12. 

Trichiasis,  256. 

Trifacial  neuralgia,  245. 

True  aneurism,  93. 

Tube  for  trachea,  342. 

Tubercular,  osteo-arthritis  in  dislocation,  185; 
lymphoma,  of  cervical  glands,  332. 

Tuberculosis,  of  joints,  202;  of  tendons,  227;  of 
hip-joint,  203;  of  mammary  gland,  359;  in 
ununited  fractures,  182;  of  rectum,  500;  of 
colon,  500;  of  prostate,  557;  Bier's  method  of 
treatment  of,  756;  of  pancreas,  413;  of  testis, 
598;  of  epididymis,  598,  755;  of  scalp,  229. 

Tuberculous  inflammation  of  bone,  145;  osteo- 
myelitis, 145;  ostitis,  145;  periostitis,  144; 
synovitis  of  ankle-joint,  215;  osteo-arthritis 
of  shoulder-joint,  217;  of  elbow-joint,  217;  of 
■wrist-joint,  217;  adenitis,  85;  symptoms  of, 
treatment  of,  86;  endocervicitis,  606;  peri- 
tonitis, 451. 

Tufnell  method  of  treating  aneurism,  95,  101. 

Tumors,  of  larjmgo-pharjmx,  removal  of,  341 ; 
of  neck,  332;  of  cervical  glands,  332;  of 
palate,  317;  of  parotid  gland,  308;  of  kidney, 
506;  of  heart,  369;  of  breast,  357;  of  brain, 
removal  of,  235;  of  scalp,  229;  of  eyelids,  251 ; 
of  brain,  237;  of  ovary,  631,  636;  of  paro- 
varium, 636;  of  hand,  691;  of  cauda  equina, 
classification  of,  698;  differentiation  betiveen 
benign  and  malignant,  719,  720. 

Timica  funiculi  hj'drocele  of,  592. 

Tuttle,  J.  P.,  modification  of  Quemi's  opera- 
tion, 487^89;  position,  429;  case  of  carcino- 
ma, 431;  case  of  artificial  anus,  434,  435. 

Tympanum,  inflation  of,  286. 

Typhoid  ulcer,  428. 

Ulcer,  of  rectum,  482 ;  of  penis,  585 ;  non-specific, 
585;  of  herpes,  585;  phagedenic,  of  penis, 
586,  .587;  of  vulva,  604,  780;  typhoid,  428; 
of  stomach,  381;  location  of,  382;  treatment 
of,  382;  of  duodenum,  398;  of  scalp,  230;  of 
cornea,  262;  of  tongue,  326. 

Ulceration  of  palate,  317. 

Ulcus  serpens,  262;  cornea,  262. 

Ulna,  fracture  of,  161 ;  of  shaft,  163;  of  corouoid 
process,  163;  dislocation  of,  at  elbow,  191- 
193;  injury  to,  in  dislocation  at  elbow,  192. 

Ulnar  artery,  aneurism  of,  106;  hgation  of,  133, 
134. 

Umbilical  hernia,  456,  471 ;  Mayo's  operation 
for,  472,  473. 

Umbo  of  tympanum.  285. 

Ununited  fracture,  181. 

Upper  extremity,  deformities  of,  681. 

Ureters,  508,  509,  510,  511,  512,  513;  stricture 
of,  509;  anastomosis  of,  510;  Deaver's 
method,  509;  Bartlett's  method,  509;  Van 
Hook's  method,  510;  catheterization  of,  512; 
Kelly's  method,  512,  513;  Pawlik's  method, 
513,  514. 

Urethra,  changes  in  contour  due  to  hyper- 
trophy, 554,  555;  neoplasms  of,  580;  con- 
genital malformations  of,  577;  calculi  in, 
573;  foreign  bodies  in,  573;  caruncle  of,  623; 
stricture  of  the  male,  563. 

Urethral,  endoscope,  Ivlotz,  564;  divulsion  of 
stricture,  567;  fistula,  574;  sounds,  572; 
bougies,  573. 

Urethritis,  non-specific,  563,  762;  chronic,  563; 
chronic  follicular,  563,  758. 

Urethro-perineal  fistula,  operation  for,  575,  576. 


Urethrotome,  Otis'  dilating,  567. 

Urethrotomy,  internal,  566;  external,  566; 
haemorrhage  after  internal,  568;  internal 
modified,   569;  external  modified,   570. 

Urinary,  calculi,  533;  fistula,  574. 

Urine,  528,  529;  incontinence  of,  525;  sup- 
pression of,  526;  sugar  in,  530;  parasites  in, 
533;  retention  of,  561. 

Uterus,  deformities  of,  611;  displacements  of, 
611;  anteflexion  of,  611;  retroversion  of ,  612 ; 
carcinoma  of,  628;"fibroids  of,  628;  curettage 
of,  627;  inversion  of,  627;  myoma  of,  628; 
sarcoma  of,  630. 

U\Tila,  317;  excision  of,  317. 

Vagina,  spasm  of,  606;  hernia  of,  456,   474; 

stricture  of,  607;  lacerations  of,  612:  absence 

of,  623;  hysterectomy,  operation  for,   635; 

neoplasms  of,  623;  abscess  of,  623. 
Vaginismus,  606. 
Vaginitis,  605. 
Valentine's  meat  juice  for  colon  alimentation, 

350. 
Valgum,  genu,  660,  661. 
Valgus,  talipes,  673;  hallux,  677. 
Valsalva's  method  of  treating  aneurism,  95,  101. 
Van  ArsAle,  W.  W.,  reduction  of  clislocated 

humerus,  191. 
Vance  corset,  210;  osteotome,  10. 
Van  Hook,  operation  for  wounds  of  ureter,  510; 

method  of  forming  new  meatus,  578. 
Van  Horn  and  Sawtell  catgut,  5. 
Varicocele,  594,  595. 
Varicose  veins,  or  venous  varix,  etiology,  90; 

dangers  of,  91;  treatment  of,  91,  92;  with 

occlusion  of  popliteal  or  femoral  veins,  91 ; 

Babcock's    operation    for    removal   of,    92; 

Mayo's  method,  91,  92;    Schaede's  method, 

92;  aneurism,  93,  94. 
Varum,  genu,  660,  664. 
■\'arus,  talipes,  668;  hallux,  677. 
Vascular  tumors,  87;  classification  of,  87. 
A'egetable  parasites  in  ear,  285. 
Veins,  wounds  of,  109;  suture  of,  109;  Lembert's 

method  of  suturing,  110:  ligation  of  internal 

jugulars,  126;  phlebitis,  86;  pathology  of,  86; 

varix  of,  90;  median  basilic,  45;  for  intra- 
venous injection  of,  45;  cephalic,  45. 
Velpeau's  bandage,  for  fractured  clavicle,  155, 

186;  for  fracture  of  coracoid  process,   156. 
Venereal  diseases,  758. 
Venom  of  snakes,  45. 
Venous,  angeioma,88;  Wyeth's  treatment  of,  88; 

technic,  89;  dangers  of,  89;  varix,  see  varicose 

veins,  90. 
Ventral  hernia,  456.  , 

Ventricles  of  brain,  aspiration  of,  243. 
Vertebrae,  dislocation  of,  201;  fracture  of,  166. 
Vertebral  arterj^  aneurism  of,  103;  relations  of, 
,   129;  ligation  of,  131. 
Vesico-vaginal  fistula,  623,  624. 
Vessels,  lymphatic  infection  of,  85. 
Vitreous,  270. 
Volkmann's  spoons,  11;  sliding  foot  piece,  175; 

operation  for  hydrocele,  592;  anterior  splint, 

222. 
Volvulus,  416. 
Von  Graefe's  strabismus  hook,  272;  operation 

for  conical  cornea,  263. 
Vulva,  ulcers  of,  604;  wounds  of,  605. 
Vulvae,  pruritus,  604. 
Vulvitis,  603. 
Vulvo-vaginal,  abscess,  603;  outlet,  relaxation 

of,  617;  operation  for,  618-621. 


816 


INDEX 


Walker,  A.  C,  operation  for  gunshot  wound, 
519. 

Wardrop's  method  of  treating  aneurism,  96. 

Ward  well,  W.  L.,  gangrene,  784. 

Warren,  John  Collins,  comi^leted  healing  of 
wounds,  371;  removal  of  breast,  361. 

Warts,  of  eyelids,  251 ;  of  nostrils,  295;  of  scalp, 
229. 

Wasserman,  Melville,  epithelioma  of  urethra, 
580. 

AVeb-finger,  685. 

Webster,  David,  pannus,  262;  treatment  of 
hordeolum,  251. 

Weights,  791;  and  measures,  791. 

Weir,  Robert,  platinum  support  for  nose,  301. 

Wens  of  scalp,  229. 

Whey  for  colon  alimentation,  350. 

Whisky,  in  snake-bite,  46;  in  syncope,  45. 

Whitehead,  operation  for  hsemorrhoids,  495. 

Whitlow,  689. 

Whitman,  Royal,  fracture  of  neck  of  femur, 
171;  congenital  dislocation,  681. 

Wiener,  Jos.,  Jr.,  case  of  hernia,  475. 

Wilms,  massage  of  heart,  368. 

Wire,  breeches  of  Sayre,  211,  218;  screen,  175. 

Wolff  operation  for  ptosis,  253. 

Wolverton's  tooth  forceps,  316. 

Wood,  method  of  treatment  of  double  penis, 
517. 

Wounds,  42;  classification  of,  42;  incised,  42; 
pmictured,  42;  lacerated,  42;  contused,  42; 
leucocytes,  42;  aseptic,  42;  treatment  of,  42; 
suture  of,  43;  clot,  serum  and  dead  tissue  in, 
43;  drainage,  43;  upon  face,  43;  three- 
cornered,  44;  metal  clips  in,  44;  poisoned 
wounds,  45;  gunshot,  46,  47;  of  liver,  47;  of 
thyroid  body,  334;  of  neck,  331;  of  tongue, 
335;  of  kidneys,  502;  of  bladder,  517;  of 
penis,  580;  of  scrotum,  588;  of  vulva,  605;  of 


hver,  402;  of  stomach,  379;  of  heart,  367;  of 
abdomen,  374;  of  chest,  365;  of  eyelids,  251; 
of  arteries,  109;  of  veins,  109;  of  cornea,  261 ; 
of  scalp,  232;  of  membrana  tympani,  286;  of 
auricle  of  ear,  283. 

Wrist-joint,  dislocation  of,  193;  exsection  of, 
225;  thecitis  of,  217. 

Wry-neck,  638. 

Wyeth's  treatment  of  vascular  tumors,  88,  89, 
90;  operation  for  arterial  angeioma  (cirsoid 
aneurism),  88;  for  venous  angeioma,  88;  for 
capillary  angeioma,  89,  90;  hot  water 
syringe,  88;  shoulder-joint  amputation,  61 ; 
hip-joint  amputation,  75;  pins,  76;  conclu- 
sions as  to  arterial  occlusion  after  ligation, 
42;  ligature  forceps,  42;  deligation  of  e:x- 
ternal  carotid,  103 ;  bandage  for  hand,  thumb, 
and  fingers,  31;  foot  bandage,  34;  drills  in 
exsection  of  knee-joint,  221 ;  of  ankle-joint, 
222;  exsector,  19,  22,  218;  operation  for  large 
tumors  of  antrum  of  Highniore,  310;  opera- 
tion for  microcephalus,  232;  operation  for 
excision  of  lower  jaw,  313;  conclusions  as  to 
arterial  occlusion  after  ligation.  111;  drills, 
168. 

X-ray  in  fracture  of  glenoid  process,  156;  about 
elbow,  157;  of  humerus,  156;  in  fractures,  147, 
148;  of  coronoid  process,  163;  in  gunshot 
wounds  of  skull  and  brain,  233;  in  lupus 
vulgaris,  304;  for  foreign  bodies  in  air 
passages,  344. 

Y  fracture  at  elbow,  158. 

Young,  Hugh  H.,  operation  for  perineal 
prostatectomy,  550,  553. 

Zygomatic  process,  fracture  of,  152. 


